MEDICARE: HEALTHSTAT ONSITE CLINIC HSM FORT SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician

General Provider Information

NPI Number	:	1235640384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSTAT ONSITE CLINIC HSM FORT SMITH

Provider Business Mailing Address
First Line	:	4651 CHARLOTTE PARK DR STE 300
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-1916
Country	:	US
Telephone Number	:	704-935-5546
Fax Number	:

Provider Business Practice Location Address
First Line	:	4925 STATE LINE RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-4145
Country	:	US
Telephone Number	:	479-646-6161
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF RISK MANAGEMENT
Name	:	JILL JOHNSON PATTON
Credential	:
Telephone Number	:	704-936-5546

Provider Enumeration Date	:	10/17/2017
Last Update Date	:	10/17/2017

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