Provider Demographics
NPI:1174588784
Name:ST. MARY - ROGERS MEMORIAL HOSPITAL DBA FRIENDS HOUSE
Entity type:Organization
Organization Name:ST. MARY - ROGERS MEMORIAL HOSPITAL DBA FRIENDS HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-936-2843
Mailing Address - Street 1:1200 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3546
Mailing Address - Country:US
Mailing Address - Phone:479-636-0200
Mailing Address - Fax:479-986-3469
Practice Address - Street 1:1200 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3546
Practice Address - Country:US
Practice Address - Phone:479-636-0200
Practice Address - Fax:479-986-3469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR040385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95007597Medicaid
LA1765261Medicaid
OH0866460Medicaid
IA0987149Medicaid