Provider Demographics
NPI:1346453560
Name:JOE B. PEVAHOUSE M.D. P.A
Entity Type:Organization
Organization Name:JOE B. PEVAHOUSE M.D. P.A
Other - Org Name:RENAL ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:B
Authorized Official - Last Name:PEVAHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-224-2141
Mailing Address - Street 1:9601 LILE DR STE 350
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6356
Mailing Address - Country:US
Mailing Address - Phone:501-224-2141
Mailing Address - Fax:
Practice Address - Street 1:9601 LILE DR STE 350
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6356
Practice Address - Country:US
Practice Address - Phone:501-224-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR54035Medicare ID - Type Unspecified
ARD17040Medicare UPIN