# RUSSELLVILLE GASTROENTEROLOGY CLINIC PA

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

## Provider details

- **NPI number:** 1750579488
- **Authorized official:** MS. DENISE ROBERTSON (OWNER)
- **Authorized official phone:** (479) 890-5881

## Contact information

- **Practice address:** 1611 W MAIN ST, RUSSELLVILLE, AR 72801-2719
- **Practice address phone:** (479) 890-5881
- **Practice address fax:** (479) 890-5092
- **Mailing address:** 1611 W MAIN ST, RUSSELLVILLE, AR 72801-2719
- **Mailing address phone:** (479) 890-5881
- **Mailing address fax:** (479) 890-5092

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | C6004 | AR | Yes |
| 261QM2500X | Medical Specialty Clinic/Center | — | AR | — |

## Other

- **Enumeration date:** 10/09/2007
- **Last updated:** 01/22/2015