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General NPI Number Information
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NPI Number | 1275541427
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Entity Type | Organization
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Legal Business Name | PINE BLUFF ENDOSCOPY CENTER, LLC
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 11/25/2013
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Provider Practice Location Address
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Address Line | 1609 W 40TH AVE SUITE 312
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City | PINE BLUFF
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State | AR
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Zip | 71603-6319
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Country | US
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Telephone | 870-534-2626
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Fax | 870-534-3517
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Provider Business Mailing Address
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Address Line | 1609 W 40TH AVE SUITE 312
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City | PINE BLUFF
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State | AR
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Zip | 71603-6319
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Country | US
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Telephone | 870-534-2626
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Fax | 870-534-3517
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | O.T. GORDON JR.
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Credential | M.D.
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Telephone | 870-534-3344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0800X
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Taxonomy Name | Endoscopy Clinic/Center
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License Number | AR4347
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License Number State | AR
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