Provider Demographics
NPI:1407966005
Name:PEDIATRIC ASSOCIATES OF WEST MEMPHIS, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF WEST MEMPHIS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-732-1191
Mailing Address - Street 1:108 W TYLER
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4221
Mailing Address - Country:US
Mailing Address - Phone:870-732-1191
Mailing Address - Fax:870-732-4091
Practice Address - Street 1:108 W TYLER
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4221
Practice Address - Country:US
Practice Address - Phone:870-732-1191
Practice Address - Fax:870-732-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
AR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152363002Medicaid
AR57372Medicare UPIN