Provider Demographics
NPI:1710106042
Name:MECUM, GIDEON S (MD)
Entity Type:Individual
Prefix:
First Name:GIDEON
Middle Name:S
Last Name:MECUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 E MOCKERNUT XING
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4938
Mailing Address - Country:US
Mailing Address - Phone:479-236-0470
Mailing Address - Fax:
Practice Address - Street 1:3215 N. NORTH HILL DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4424
Practice Address - Country:US
Practice Address - Phone:479-463-7102
Practice Address - Fax:479-463-7864
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6020207PP0204X, 208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177619001Medicaid
AR5H773Medicare PIN