NPIMap

Individual provider Active NPI

Cristina M Clark

  • Obstetrics & Gynecology Physician
  • Russellville, AR
National Provider Identifier
1588807135
Registry record updated Feb 25, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
License
E-7931 Issued in AR
Practice address
105 Skyline Dr
Russellville, AR 72801-3363
Phone
(479) 968-2345
Fax
(479) 890-7125
NPI assigned
Apr 13, 2009
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 25, 2015

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Obstetrics & Gynecology Physician 207V00000X E-7931 AR Primary

Addresses

Primary practice location

105 Skyline Dr
Russellville, AR 72801-3363

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
197270001MedicaidAR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20130430000028 AR Practitioner - Obstetrics/Gynecology 7012153596 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Obstetrics/Gynecology
Education
Other, 2008
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
St Marys Physician Services LLCGroup PAC ID 4981698032, 49 clinicians

Practice addresses (Care Compare)

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

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

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
E-7931ARMDObstetrics & Gynecology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
St Mary's Physician Services LLC CurrentSince May 1, 2013 Accepting new patients
Springdale- Bentonville HBP Services, LLC CurrentSince Dec 31, 2025 Accepting new patients
St Marys Physician Services, LLC CurrentSince May 1, 2013 Accepting new patients
St Marys Physician Services, LLC Past Accepting new patients

Locations

3000 Medical Center Pkwy
Bentonville, AR 72712
Phone (479) 553-2524

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

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

Interoperability endpoints

  • Direct secure messaging: cristina.clark.1@2433.direct.athenahealth.com

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1239580800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1424822400000",
    "number": "1588807135",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "105 SKYLINE DR",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728013363",
            "telephone_number": "479-968-2345",
            "fax_number": "479-890-7125"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 SKYLINE DR",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728013363",
            "telephone_number": "479-968-2345",
            "fax_number": "479-890-7125"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "CRISTINA",
        "middle_name": "M",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2009-04-13",
        "last_updated": "2015-02-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "AR",
            "license": "E-7931",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "197270001",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Russellville, AR

Sources for this page

Verify at the official NPI Registry.