=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144268509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARKANSAS HEALTH GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2006
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 S MAIN ST
-----------------------------------------------------
City | SEARCY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72143-7319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-268-7143
-----------------------------------------------------
Fax | 501-268-7198
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11001 EXECUTIVE CENTER DR STE 200
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-812-7201
-----------------------------------------------------
Fax | 501-812-7507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CMA
-----------------------------------------------------
Name | MS. KIM TITSWORTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-812-7512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------