Provider Demographics
NPI:1679567408
Name:CARDIOLOGY AND MEDICINE CLINIC P A
Entity type:Organization
Organization Name:CARDIOLOGY AND MEDICINE CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:FERGUSON
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-664-0941
Mailing Address - Street 1:5315 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1858
Mailing Address - Country:US
Mailing Address - Phone:501-664-0941
Mailing Address - Fax:501-666-3956
Practice Address - Street 1:5315 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1858
Practice Address - Country:US
Practice Address - Phone:501-664-0941
Practice Address - Fax:501-666-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145330002Medicaid
D9086OtherRAILROAD MEDICARE
AR5B371OtherBLUE CROSS/BLUE SHIELD
D9086OtherRAILROAD MEDICARE