Provider Demographics
NPI:1023233012
Name:FRANK G THIBAULT MD, PA
Entity type:Organization
Organization Name:FRANK G THIBAULT MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:G
Authorized Official - Last Name:THIBAULT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-315-7774
Mailing Address - Street 1:910 N EAST ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3327
Mailing Address - Country:US
Mailing Address - Phone:501-315-7774
Mailing Address - Fax:501-315-7772
Practice Address - Street 1:910 N EAST ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3327
Practice Address - Country:US
Practice Address - Phone:501-315-7774
Practice Address - Fax:501-315-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105455001Medicaid
ARE2094OtherELECTRONIC SUBMITTER
AR105455001Medicaid