=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285739292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANNY E GRUBBS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 07/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3202 METHODIST DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-7408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-932-2221
-----------------------------------------------------
Fax | 870-931-3229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3202 METHODIST DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-7408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-932-2221
-----------------------------------------------------
Fax | 870-931-3229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHYSICIAN
-----------------------------------------------------
Name | DANNY E GRUBBS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 870-932-2221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | C5642
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------