=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134558398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST VINCENT PHYSICIAN CLINICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2013
-----------------------------------------------------
Last Update Date | 05/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16221 SAINT VINCENT WAY
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72223-9072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-552-8150
-----------------------------------------------------
Fax | 501-552-8199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5125 NORTHSHORE DR
-----------------------------------------------------
City | NORTH LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72118-5315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-224-1690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR-REVENUE CYCLE
-----------------------------------------------------
Name | JAIME DENNIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-224-1690
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------