Provider Demographics
NPI:1568791135
Name:M. BRUCE SANDERSON MD PA
Entity Type:Organization
Organization Name:M. BRUCE SANDERSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:M
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-664-5119
Mailing Address - Street 1:500 S UNIVERSITY AVE STE 701
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5309
Mailing Address - Country:US
Mailing Address - Phone:501-664-5119
Mailing Address - Fax:501-664-4209
Practice Address - Street 1:500 S UNIVERSITY AVE STE 701
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5309
Practice Address - Country:US
Practice Address - Phone:501-664-5119
Practice Address - Fax:501-664-4209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104566001Medicaid
AR54670Medicare PIN