NPIMap

Organization Active NPI

Executive Park Surgery Center, LLC

  • Ambulatory Surgical Clinic/Center
  • Fort Smith, AR
National Provider Identifier
1699736777
Registry record updated Dec 16, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
Legal business name
EXECUTIVE PARK SURGERY CENTER, LLC
Practice address
3314 S 70TH St
Fort Smith, AR 72903-5052
Phone
(479) 424-2744
Fax
(479) 424-2745
NPI assigned
Mar 29, 2006
Last updated
Dec 16, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 16, 2010

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

Authorized official

Name
Randy M Ennen, M.D.NPI 1124089222
Title
President
Phone
(479) 424-2744

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X NU Primary

Addresses

Primary practice location

3314 S 70TH St
Fort Smith, AR 72903-5052

Mailing address

3314 S 70TH St
Fort Smith, AR 72903-5052
Phone (479) 424-2744

Other identifiers 2

IdentifierTypeStateIssuer
155824128MedicaidAR
200041770AMedicaidOK

National Provider Directory

National Provider Directory

Locations

3312 S 70th St
Fort Smith, AR 72903
Phone (479) 424-2744

Practitioners & affiliated clinicians

Practitioners 2

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.

NPI Registry JSON

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

{
    "created_epoch": "1143590400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1292457600000",
    "number": "1699736777",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3314 S 70TH ST",
            "city": "FORT SMITH",
            "state": "AR",
            "postal_code": "729035052",
            "telephone_number": "479-424-2744",
            "fax_number": "479-424-2745"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3314 S 70TH ST",
            "city": "FORT SMITH",
            "state": "AR",
            "postal_code": "729035052",
            "telephone_number": "479-424-2744",
            "fax_number": "479-424-2745"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EXECUTIVE PARK SURGERY CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-29",
        "last_updated": "2010-12-16",
        "status": "A",
        "authorized_official_last_name": "ENNEN",
        "authorized_official_first_name": "RANDY",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "479-424-2744",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "155824128",
            "state": "AR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200041770A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Smith, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 16, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.