MEDICARE: CROSSETT HEALTH FOUNDATION

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	207RH0003X	Hematology & Oncology Physician	C8506	AR
2	2084P0800X	Psychiatry Physician
3	207Y00000X	Otolaryngology Physician
4	207YP0228X	Pediatric Otolaryngology Physician

General Provider Information

NPI Number	:	1548252745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSETT HEALTH FOUNDATION

Provider Business Mailing Address
First Line	:	1015 UNITY RD
Second Line	:
City	:	CROSSETT
State	:	AR
Zip	:	71635-9443
Country	:	US
Telephone Number	:	870-364-1291
Fax Number	:	870-364-1479

Provider Business Practice Location Address
First Line	:	1015 UNITY RD
Second Line	:
City	:	CROSSETT
State	:	AR
Zip	:	71635-9443
Country	:	US
Telephone Number	:	870-364-1291
Fax Number	:	870-364-1479

Authorized Official
Title or Position	:	CFO
Name	:	MRS. SHANNON CLARK
Credential	:
Telephone Number	:	870-364-4111

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	10/01/2007

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Directions to “CROSSETT HEALTH FOUNDATION ” Practice Location

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