MEDICARE: BAPTIST HEALTH FAMILY CLINIC PROTHO

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	R2917	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710225545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAPTIST HEALTH FAMILY CLINIC PROTHO

Provider Business Mailing Address
First Line	:	11001 EXECUTIVE CENTER DR
Second Line	:	SUITE 200
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-4316
Country	:	US
Telephone Number	:	501-812-7512
Fax Number	:	501-812-7507

Provider Business Practice Location Address
First Line	:	5207 E BROADWAY ST
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72117-4029
Country	:	US
Telephone Number	:	501-945-2033
Fax Number	:	501-945-2303

Authorized Official
Title or Position	:	CEO
Name	:	MR. WILL RUSHER
Credential	:
Telephone Number	:	501-812-7512

Provider Enumeration Date	:	01/29/2013
Last Update Date	:	01/29/2013

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