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General NPI Number Information
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NPI Number | 1932690617
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Entity Type | Organization
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Legal Business Name | PROVIDENCE FAMILY MEDICINE CLINIC INC
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Dates
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Enumeration Date | 05/29/2018
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Last Update Date | 05/29/2018
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Provider Practice Location Address
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Address Line | 3900 DAVE WARD DR
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City | CONWAY
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State | AR
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Zip | 72034-5583
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Country | US
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Telephone | 501-499-1086
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Fax |
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Provider Business Mailing Address
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Address Line | 8 OAK TREE CIR
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City | CONWAY
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State | AR
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Zip | 72032-2112
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Country | US
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Telephone | 501-499-1086
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MOHAMMAD IDRIS
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Credential | MD
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Telephone | 501-499-1086
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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