# ST MARY'S PHYSICIAN SERVICES LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1124084991
- **Authorized official:** CHARLOTTE LAWRENCE (SECRETARY)
- **Authorized official phone:** (615) 920-7000

## Contact information

- **Practice address:** 101 SKYLINE DR, RUSSELLVILLE, AR 72801-3363
- **Practice address phone:** (479) 968-2345
- **Practice address fax:** (479) 890-2497
- **Mailing address:** 101 SKYLINE DR, RUSSELLVILLE, AR 72801-3363
- **Mailing address phone:** (479) 968-2345

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 04/21/2006
- **Last updated:** 09/26/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 152955002 | — | AR |
| 01 | — | DA8026 | RAILROAD MEDICARE PTAN | — |