Provider Demographics
NPI:1861786774
Name:ST VINCENT MEDICAL GROUP
Entity type:Organization
Organization Name:ST VINCENT MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVALERIA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-552-4710
Mailing Address - Street 1:2500 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3008
Mailing Address - Country:US
Mailing Address - Phone:501-552-4710
Mailing Address - Fax:501-376-2084
Practice Address - Street 1:2500 E 6TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3008
Practice Address - Country:US
Practice Address - Phone:501-552-4710
Practice Address - Fax:501-376-2084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty