Provider Demographics
NPI:1679784367
Name:SPARKS REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:SPARKS REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPARKS PROVIDER RELATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-709-7057
Mailing Address - Street 1:PO BOX 1824
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72902-1824
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1500 DODSON AVE
Practice Address - Street 2:STE 290
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5182
Practice Address - Country:US
Practice Address - Phone:479-709-7399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR239213ES0103X
AR332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200116230AMedicaid
AR5A434Medicare PIN