=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245230341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL E CLEVENGER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2005
-----------------------------------------------------
Last Update Date | 04/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 HAWKINS DR
-----------------------------------------------------
City | SEARCY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72143-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-278-2800
-----------------------------------------------------
Fax | 501-278-3073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 HAWKINS DR
-----------------------------------------------------
City | SEARCY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72143-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-278-2800
-----------------------------------------------------
Fax | 501-278-3073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | J8964
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | E4264
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------