MEDICARE: SALEM FAMILY PRACTICE CLINIC,PA

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	261Q00000X	Clinic/Center	MC1718	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	5F075	OTHER	AR	MEDICARE GROUP PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5F075	OTHER	AR	BCBS

General Provider Information

NPI Number	:	1578591129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALEM FAMILY PRACTICE CLINIC,PA

Provider Business Mailing Address
First Line	:	6640 CONGO RD
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-6913
Country	:	US
Telephone Number	:	501-794-4110
Fax Number	:	501-316-9360

Provider Business Practice Location Address
First Line	:	6640 CONGO RD
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-6913
Country	:	US
Telephone Number	:	501-794-4110
Fax Number	:	501-316-9360

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	DR. PATRICIA G MCGARRY
Credential	:	M.D.
Telephone Number	:	501-794-4110

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	11/16/2007

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