=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548239247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARKANSAS HEALTH GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 02/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1110 W VINE ST
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72150-7804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-942-5155
-----------------------------------------------------
Fax | 870-942-8791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11001 EXECUTIVE CENTER DR SUITE 200
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-812-7800
-----------------------------------------------------
Fax | 501-812-7851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. CLYDE D PAULK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 870-942-5155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C3204
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------