Russellville Gastroenterology Clinic PA

Primary specialty

Medical Specialty Clinic/CenterTaxonomy code 261QM2500X

License

C6004 Issued in AR

Legal business name

RUSSELLVILLE GASTROENTEROLOGY CLINIC PA

Practice address

1611 W Main St
Russellville, AR 72801-2719

Phone

(479) 890-5881

Fax

(479) 890-5092

NPI assigned

Oct 9, 2007

Organization subpart

No

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

Authorized official

Name

Ms. Denise Robertson

Title

Owner

Phone

(479) 890-5881

Specialties & licenses 2

Addresses

Other identifiers 1

Locations

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

{
    "created_epoch": "1191888000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1421884800000",
    "number": "1750579488",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1611 W MAIN ST",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728012719",
            "telephone_number": "479-890-5881",
            "fax_number": "479-890-5092"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1611 W MAIN ST",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728012719",
            "telephone_number": "479-890-5881",
            "fax_number": "479-890-5092"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RUSSELLVILLE GASTROENTEROLOGY CLINIC PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-09",
        "last_updated": "2015-01-22",
        "status": "A",
        "authorized_official_last_name": "ROBERTSON",
        "authorized_official_first_name": "DENISE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "479-890-5881",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": "AR",
            "license": "C6004",
            "primary": true
        },
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": "AR",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "112265001",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Medical Specialty Clinic/Center in Russellville, AR
• Providers in Russellville, AR by specialty
• Medical Specialty Clinic/Center in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 22, 2015; 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.