Provider Demographics
NPI:1902832330
Name:LITTLE ROCK CANCER CLINIC, P.A.
Entity Type:Organization
Organization Name:LITTLE ROCK CANCER CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-661-1822
Mailing Address - Street 1:500 S UNIVERSITY AVE STE 606
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5308
Mailing Address - Country:US
Mailing Address - Phone:501-661-1822
Mailing Address - Fax:501-666-0266
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 811
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-661-1822
Practice Address - Fax:501-666-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5239121OtherAETNA
AR130483002Medicaid
472130OtherHEALTHLINK PPO
1902832330OtherMERCY HEALTH PLANS
04D0922485OtherC.L.I.A. NUMBER FOR LAB
472130OtherHEALTHLINK PPO
=========OtherTRICARE
472130OtherHEALTHLINK PPO