Provider Demographics
NPI:1144559287
Name:SALINE PHYSICIAN SERVICES, LLC
Entity type:Organization
Organization Name:SALINE PHYSICIAN SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TITSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-776-6093
Mailing Address - Street 1:PO BOX 1615
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72145-1615
Mailing Address - Country:US
Mailing Address - Phone:501-653-0353
Mailing Address - Fax:501-653-0347
Practice Address - Street 1:319 BRYANT AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-3815
Practice Address - Country:US
Practice Address - Phone:501-653-0353
Practice Address - Fax:501-653-0347
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALINE COUNTY MEDICAL SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-21
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182164002Medicaid
AR5G433Medicare PIN
AR182164002Medicaid