MEDICARE: PREMISE HEALTH OF ARKANSAS MEDICAL P A

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1689154189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF ARKANSAS MEDICAL P A

Provider Business Mailing Address
First Line	:	5500 MARYLAND WAY STE 120
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4993
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4105 NEWLON RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72904-2126
Country	:	US
Telephone Number	:	479-974-1270
Fax Number	:	479-494-6364

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PETER J VASQUEZ
Credential	:	MD
Telephone Number	:	844-407-7557

Provider Enumeration Date	:	08/15/2018
Last Update Date	:	04/29/2020

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