NPIMap

Organization Active NPI

St Mary's Physician Services LLC

  • General Practice Physician
  • Russellville, AR
National Provider Identifier
1124084991
Registry record updated Sep 26, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
ST MARY'S PHYSICIAN SERVICES LLC
Practice address
101 Skyline Dr
Russellville, AR 72801-3363
Phone
(479) 968-2345
Fax
(479) 890-2497
NPI assigned
Apr 21, 2006
Last updated
Sep 26, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 26, 2024

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

Authorized official

Name
Charlotte Lawrence
Title
Secretary
Phone
(615) 920-7000

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X NU
General Practice Physician 208D00000X NU Primary

Addresses

Primary practice location

101 Skyline Dr
Russellville, AR 72801-3363

Mailing address

101 Skyline Dr
Russellville, AR 72801-3363
Phone (479) 968-2345

Other identifiers 2

IdentifierTypeStateIssuer
152955002MedicaidAR
DA8026OtherRAILROAD MEDICARE PTAN

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040609000759 AR Part B Supplier - Clinic/Group Practice 4981698032 Receives reassigned benefits from 137 practitioners
1 other NPI on this enrollment
Practice locations: Atkins, AR; Dardanelle, AR; Dover, AR; Russellville, AR

Other NPIs with the same Medicare PAC ID 1

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

Other NPIs on the same Medicare enrollment 1

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D2338829Millard Henry Clinic St Mary's Physician Services101 Skyline Drive Suite a, Russellville, AR 72801Certificate of waiverFeb 17, 2028

National Provider Directory

National Provider Directory

Locations

1601 N Church St
Atkins, AR 72823
Phone (479) 480-4066

105 Skyline Dr
Russellville, AR 72801
Phone (479) 968-2345

Practitioners & affiliated clinicians

Practitioners 140

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 140

NPI Registry JSON

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

{
    "created_epoch": "1145577600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1727308800000",
    "number": "1124084991",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "101 SKYLINE DR",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728013363",
            "telephone_number": "479-968-2345"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 SKYLINE DR",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728013363",
            "telephone_number": "479-968-2345",
            "fax_number": "479-890-2497"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST MARY'S PHYSICIAN SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-21",
        "last_updated": "2024-09-26",
        "certification_date": "2024-09-26",
        "status": "A",
        "authorized_official_last_name": "LAWRENCE",
        "authorized_official_first_name": "CHARLOTTE",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "615-920-7000"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "152955002",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE PTAN",
            "identifier": "DA8026",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Russellville, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 26, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.