NPIMap

Organization Active NPI

Bowlin-Cummins PA

Doing business as Banister-Lieblong Clinic

  • Rural Health Clinic/Center
  • Conway, AR
National Provider Identifier
1861455057
Registry record updated Jan 6, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BOWLIN-CUMMINS PA
Doing business as
Banister-Lieblong Clinic
Practice address
2425 Dave Ward Dr
Ste 401
Conway, AR 72034
Phone
(501) 329-3824
Fax
(501) 327-2957
NPI assigned
Apr 10, 2006
Last updated
Jan 6, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 6, 2015

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

Authorized official

Name
Lander A Smith, MDNPI 1861479966
Title
Chief Financial Officer
Phone
(501) 329-3824

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

2425 Dave Ward Dr
Ste 401
Conway, AR 72034

Mailing address

2425 Dave Ward Dr
Ste 401
Conway, AR 72034
Phone (501) 329-3824

Other identifiers 2

IdentifierTypeStateIssuer
156305729MedicaidAR
5B578OtherARBLUE CROSS BLUE SHEILD

Other names 1

  • Banister-Lieblong Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050126000523 AR Part A Provider - Rural Health Clinic 5698725745 Practice locations: Conway, AR
O20050129000045 AR Part B Supplier - Clinic/Group Practice 5698725745 Receives reassigned benefits from 9 practitioners
Practice locations: Conway, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1861455057. Details of each certification follow.

Rural health clinic certification: CCN 043853

Legal name
BOWLIN-CUMMINS PA
Doing business as
BANISTER LIEBLONG CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 27, 2000
Last certification
Dec 28, 2017
Ownership / control type
1B
Most recent change of ownership
Jan 1, 2005 (1 total)
Organization structure
CorporationProprietary
Enrollment address
2425 Dave Ward Dr
401
Conway, AR 72034-8681

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
04D0466251Banister-Lieblong Clinic2425 Dave Ward Drive, Suite 401, Conway, AR 72034Certificate of waiverMar 28, 2028

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Lander a Smith Individual 5% Or Greater Direct Ownership InterestMD Oct 1, 2024 16.66%
General Partnership InterestMD Jan 26, 2005
David L Naylor Individual 5% Or Greater Direct Ownership InterestMD Oct 1, 2024 16.66%
General Partnership InterestMD Jan 26, 2005
Diane Sponer Individual W-2 Managing Employee Jan 1, 2005
Bowlin-Cummins PA Organization, Conway, AR 5% Or Greater Direct Ownership Interest Jan 1, 2005
Thad R Hardin Individual 5% Or Greater Direct Ownership InterestMD Oct 1, 2024 16.66%
Randal G Bowlin Individual 5% Or Greater Direct Ownership InterestMD Oct 1, 2024 16.66%
General Partnership InterestMD Jan 26, 2005
Joe C Cummins Individual 5% Or Greater Direct Ownership InterestMD Oct 1, 2024 16.66%
General Partnership InterestMD Jan 1, 2005
John C Dickson Individual 5% Or Greater Direct Ownership InterestMD Oct 1, 2024 16.66%

Owners & managing parties with NPI records 6

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 10

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": "1144627200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1420502400000",
    "number": "1861455057",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2425 DAVE WARD DR",
            "address_2": "STE 401",
            "city": "CONWAY",
            "state": "AR",
            "postal_code": "72034",
            "telephone_number": "501-329-3824",
            "fax_number": "501-327-2957"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2425 DAVE WARD DR",
            "address_2": "STE 401",
            "city": "CONWAY",
            "state": "AR",
            "postal_code": "72034",
            "telephone_number": "501-329-3824",
            "fax_number": "501-327-2957"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOWLIN-CUMMINS PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-10",
        "last_updated": "2015-01-06",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "LANDER",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "501-329-3824",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "156305729",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHEILD",
            "identifier": "5B578",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Banister-Lieblong Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Conway, AR

Sources for this page

Verify at the official NPI Registry.