Provider Demographics
NPI:1053490144
Name:ANES W. ABRAHAM M.D. P.A.
Entity type:Organization
Organization Name:ANES W. ABRAHAM M.D. P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANES
Authorized Official - Middle Name:WILEY
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-763-1700
Mailing Address - Street 1:1521 N 10TH ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1405
Mailing Address - Country:US
Mailing Address - Phone:870-763-1700
Mailing Address - Fax:870-763-2903
Practice Address - Street 1:1521 N 10TH ST
Practice Address - Street 2:SUITE H
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1405
Practice Address - Country:US
Practice Address - Phone:870-763-1700
Practice Address - Fax:870-763-2903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3291174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57920OtherCLINIC BCBS
AR57920OtherCLINIC BCBS