MEDICARE: EASTSIDE OB/GYN P.L.L.C.

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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1396786042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTSIDE OB/GYN P.L.L.C.

Provider Business Mailing Address
First Line	:	7001 ROGERS AVE
Second Line	:	SUITE 502
City	:	FORT SMITH
State	:	AR
Zip	:	72903-4073
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7001 ROGERS AVE
Second Line	:	SUITE 502
City	:	FORT SMITH
State	:	AR
Zip	:	72903-4073
Country	:	US
Telephone Number	:	479-484-5901
Fax Number	:

Authorized Official
Title or Position	:	CODER
Name	:	GLENNA MARIE ROE
Credential	:	CPC
Telephone Number	:	479-484-5901

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	03/20/2024

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