NPIMap

Organization Active NPI

Arkansas Renal Group PA

Doing business as Russellville Nephrology

  • Nephrology Physician
  • Russellville, AR
National Provider Identifier
1922769322
Registry record updated Jan 7, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nephrology PhysicianTaxonomy code 207RN0300X
Legal business name
ARKANSAS RENAL GROUP PA
Doing business as
Russellville Nephrology
Practice address
111 Skyline Dr
Russellville, AR 72801-3363
Phone
(501) 624-6000
Fax
(501) 321-0710
NPI assigned
Jan 7, 2022
Last updated
Jan 7, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
ARKANSAS RENAL GROU PAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 7, 2022

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

Authorized official

Name
Jerry Edgin, CPA
Title
Chief Executive Officer
Phone
(501) 624-6000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nephrology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RN0300X Primary

Addresses

Primary practice location

111 Skyline Dr
Russellville, AR 72801-3363

Mailing address

115 Wrights St Ste C
Hot Springs, AR 71913-6240
Phone (501) 624-6000

Other names 1

  • Russellville Nephrology Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220406001085 AR Part B Supplier - Clinic/Group Practice 8921274721 Receives reassigned benefits from 11 practitioners
Practice locations: Russellville, AR

Other NPIs with the same Medicare PAC ID 3

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

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
04D2112078Arkansas Renal Group, PA - Russellville111 Skyline Drive, Russellville, AR 72801Certificate of waiverApr 20, 2028

National Provider Directory

National Provider Directory
Tax ID family
Arkansas Renal Group PA4 organizations share this tax ID, including this one
Part of
Arkansas Renal Group PA

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

620 W Grove St
Ste 101
El Dorado, AR 71730
Phone (870) 862-0801

115 Wrights St
#B
Hot Springs National Park, AR 71913
Phone (501) 624-6000

Practitioners & affiliated clinicians

Practitioners 21

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 21

NPI Registry JSON

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

{
    "created_epoch": "1641513600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1641513600000",
    "number": "1922769322",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "115 WRIGHTS ST STE C",
            "city": "HOT SPRINGS",
            "state": "AR",
            "postal_code": "719136240",
            "telephone_number": "501-624-6000",
            "fax_number": "501-321-0710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 SKYLINE DR",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728013363",
            "telephone_number": "501-624-6000",
            "fax_number": "501-321-0710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ARKANSAS RENAL GROUP PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ARKANSAS RENAL GROU PA",
        "enumeration_date": "2022-01-07",
        "last_updated": "2022-01-07",
        "certification_date": "2022-01-07",
        "status": "A",
        "authorized_official_last_name": "EDGIN",
        "authorized_official_first_name": "JERRY",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "501-624-6000",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "207RN0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Nephrology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Russellville Nephrology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 Jan 7, 2022; 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.