Provider Demographics
NPI:1548252745
Name:CROSSETT HEALTH FOUNDATION
Entity type:Organization
Organization Name:CROSSETT HEALTH FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-364-4111
Mailing Address - Street 1:1015 UNITY RD
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-9443
Mailing Address - Country:US
Mailing Address - Phone:870-364-1291
Mailing Address - Fax:870-364-1479
Practice Address - Street 1:1015 UNITY RD
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-9443
Practice Address - Country:US
Practice Address - Phone:870-364-1291
Practice Address - Fax:870-364-1479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8506207RH0003X
2084P0800X, 207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F013Medicare ID - Type Unspecified