NPIMap

Organization Active NPI

Board of Governors of Dallas County Medical Center

Doing business as Dallas County Medical Center ER Physicians Group

  • Emergency Medical Services (Emergency Medicine) Physician
  • Fordyce, AR
National Provider Identifier
1043308935
Registry record updated Aug 12, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emergency Medical Services (Emergency Medicine) PhysicianTaxonomy code 207PE0004X
License
AR4114 Issued in AR
Legal business name
BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Doing business as
Dallas County Medical Center ER Physicians Group
Practice address
201 North Clifton Street
Fordyce, AR 71742
Phone
(870) 352-6363
Fax
(870) 352-6343
NPI assigned
Oct 10, 2006
Last updated
Aug 12, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 12, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tamara K Rieves
Title
Administrator / Ceo
Phone
(870) 352-6363

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medical Services (Emergency Medicine) Physician 207PE0004X
Emergency Medical Services (Emergency Medicine) Physician 207PE0004X AR4114 AR Primary

Addresses

Primary practice location

201 North Clifton Street
Fordyce, AR 71742

Mailing address

201 North Clifton Street
Fordyce, AR 71742
Phone (870) 352-6363

Other identifiers 2

IdentifierTypeStateIssuer
148414002MedicaidAR
5C703OtherARBCBS

Other names 1

  • Dallas County Medical Center ER Physicians Group Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040302000815 AR Part B Supplier - Clinic/Group Practice 7416869300 Receives reassigned benefits from 14 practitioners
2 other NPIs on this enrollment
Practice locations: Fordyce, AR

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Board of Governors Dallas5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Nutt-Walley Clinic of Dallas County Medical CenterFordyce, AR, CCN 048515 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2018

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160438400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1470960000000",
    "number": "1043308935",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "201 NORTH CLIFTON STREET",
            "city": "FORDYCE",
            "state": "AR",
            "postal_code": "71742",
            "telephone_number": "870-352-6363",
            "fax_number": "870-352-6343"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 NORTH CLIFTON STREET",
            "city": "FORDYCE",
            "state": "AR",
            "postal_code": "71742",
            "telephone_number": "870-352-6363",
            "fax_number": "870-352-6343"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-10",
        "last_updated": "2016-08-12",
        "status": "A",
        "authorized_official_last_name": "RIEVES",
        "authorized_official_first_name": "TAMARA",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "ADMINISTRATOR /  CEO",
        "authorized_official_telephone_number": "870-352-6363"
    },
    "taxonomies": [
        {
            "code": "207PE0004X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine, Emergency Medical Services",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207PE0004X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine, Emergency Medical Services",
            "state": "AR",
            "license": "AR4114",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "148414002",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "5C703",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dallas County Medical Center ER Physicians Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fordyce, AR

Sources for this page

Verify at the official NPI Registry.