1073917274 NPI number — ARKANSAS PEDIATRIC CLINIC, PLLC

Table of content: (NPI 1073917274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073917274 NPI number — ARKANSAS PEDIATRIC CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARKANSAS PEDIATRIC CLINIC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073917274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16115 SAINT VINCENT WAY STE 320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72223-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-664-4117
Provider Business Mailing Address Fax Number:
501-664-1137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23157 I 30 STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRYANT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72022-2864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-664-4117
Provider Business Practice Location Address Fax Number:
501-664-1137
Provider Enumeration Date:
10/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PARSONS
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMIN
Authorized Official Telephone Number:
501-320-4947

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 204313002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 226133002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 148500002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 213058002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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