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220 N Phoenix Ave Russellville AR 72801-2826 | |
| (479) 880-0101 | |
| (479) 880-0118 |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 220 N Phoenix Ave, Russellville, Arkansas |
| Authorized Official Name and Position | Anthony Charles Davis (OWNER) |
| Authorized Official Contact | 4798800101 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
220 N Phoenix Ave Russellville AR 72801-2826 Ph: (479) 880-0101 | 220 N Phoenix Ave Russellville AR 72801-2826 Ph: (479) 880-0101 |
| NPI Number | 1578824934 |
|---|---|
| Provider Enumeration Date | 06/01/2012 |
| Last Update Date | 06/01/2012 |
| Medicare PECOS PAC ID | 6800051764 |
|---|---|
| Medicare Enrollment ID | O20120628000084 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1578824934 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084N0400X | Psychiatry & Neurology - Neurology | (* (Not Available)) | Primary |
| Provider Name | Anthony C Davis |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1154546166 PECOS PAC ID: 3173674116 Enrollment ID: I20090702000077 |
| Provider Name | Susan Jeanette Hooten |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1629422266 PECOS PAC ID: 7012216336 Enrollment ID: I20160509000298 |
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