Provider Demographics
NPI:1790756328
Name:PULASKI SURGERY CLINIC PA
Entity Type:Organization
Organization Name:PULASKI SURGERY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:STAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-945-4422
Mailing Address - Street 1:3401 SPRINGHILL DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-2924
Mailing Address - Country:US
Mailing Address - Phone:501-945-4422
Mailing Address - Fax:501-945-4424
Practice Address - Street 1:3401 SPRINGHILL DR
Practice Address - Street 2:SUITE 400
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2924
Practice Address - Country:US
Practice Address - Phone:501-945-4422
Practice Address - Fax:501-945-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0000000878208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111089102Medicaid
AR57210Medicare ID - Type Unspecified