Provider Demographics
NPI:1508846189
Name:LITTLE ROCK CHILDREN'S CLINIC, P.A.
Entity Type:Organization
Organization Name:LITTLE ROCK CHILDREN'S CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-537-3141
Mailing Address - Street 1:9600 BAPTIST HEALTH DR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6326
Mailing Address - Country:US
Mailing Address - Phone:501-227-6727
Mailing Address - Fax:501-223-9462
Practice Address - Street 1:9600 BAPTIST HEALTH DR
Practice Address - Street 2:SUITE 360
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6326
Practice Address - Country:US
Practice Address - Phone:501-227-6727
Practice Address - Fax:501-223-9462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104443002Medicaid
AR56838Medicare ID - Type UnspecifiedMEDICARE/BLUE CROSS GROUP