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General NPI Number Information
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NPI Number | 1750579488
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Entity Type | Organization
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Legal Business Name | RUSSELLVILLE GASTROENTEROLOGY CLINIC PA
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 01/22/2015
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Provider Practice Location Address
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Address Line | 1611 W MAIN ST
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-2719
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Country | US
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Telephone | 479-890-5881
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Fax | 479-890-5092
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Provider Business Mailing Address
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Address Line | 1611 W MAIN ST
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-2719
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Country | US
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Telephone | 479-890-5881
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Fax | 479-890-5092
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Authorized Official
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Title or Position | OWNER
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Name | MS. DENISE ROBERTSON
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Credential |
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Telephone | 479-890-5881
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | C6004
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State | AR
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