04D2111712 CLIA NUMBER - NORTHSIDE CLINIC AT 6TH ST

Laboratory Demographics

  • CLIA Code: 04D2111712
  • Facility Name: NORTHSIDE CLINIC AT 6TH ST
  • Facility Address: 3202 NORTH 6TH ST
    FORT SMITH, AR
    ZIP 72904
  • Facility Phone: 479 783-3900
  • Facility Type: Federally Qualified Health Center
  • Facility Type: Microscopy
  • Lab Director: DR. MARIE PHAM-RUSSELL
  • NPI Number: 1568647519
  • Taxonomy: 261QF0400X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 04D2111712
LAB Type Federally Qualified Health Center
Facility Name NORTHSIDE CLINIC AT 6TH ST
Street 3202 NORTH 6TH ST
City FORT SMITH
State AR
ZIP 72904
Phone 479 783-3900
Certificate Type Certificate for Provider-Performed Microscopy Procedures (PPMP)
Certificate Type Description This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.
Certificate Effective Date 2/1/2024
Certificate Expiration Date 1/31/2026
Facility Type Federally Qualified Health Center
Lab Director DR. MARIE PHAM-RUSSELL

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This page was last updated on: 9/29/2025