Organization
RUSSELLVILLE GASTROENTEROLOGY CLINIC PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. DENISE ROBERTSON (OWNER)
(479) 890-5881
Entity
Organization
Contact information
Practice address
1611 W MAIN ST, RUSSELLVILLE, AR 72801-2719
(479) 890-5881
(479) 890-5092
Mailing address
1611 W MAIN ST, RUSSELLVILLE, AR 72801-2719
(479) 890-5881
(479) 890-5092
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary
C6004
AR
261QM2500X
Medical Specialty Clinic/Center
—
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
112265001
—
AR
Enumeration date
10/09/2007
Last updated
01/22/2015
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