Provider Demographics
NPI:1053397554
Name:NORTH PULASKI DIAGNOSTIC CLINIC
Entity type:Organization
Organization Name:NORTH PULASKI DIAGNOSTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-833-8400
Mailing Address - Street 1:2215 WILDWOOD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-5089
Mailing Address - Country:US
Mailing Address - Phone:501-833-8400
Mailing Address - Fax:501-833-0266
Practice Address - Street 1:2215 WILDWOOD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-5089
Practice Address - Country:US
Practice Address - Phone:501-833-8400
Practice Address - Fax:501-833-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C242Medicare ID - Type Unspecified