Provider Demographics
NPI:1821009218
Name:NORTHWEST ARKANSAS SURGICAL CLINIC, P.A.
Entity Type:Organization
Organization Name:NORTHWEST ARKANSAS SURGICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-751-3202
Mailing Address - Street 1:724 DEAVER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5356
Mailing Address - Country:US
Mailing Address - Phone:479-751-3202
Mailing Address - Fax:479-756-2721
Practice Address - Street 1:724 DEAVER ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5356
Practice Address - Country:US
Practice Address - Phone:479-751-3202
Practice Address - Fax:479-756-2721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100727600AMedicaid
AR106416002Medicaid
AR57578Medicare UPIN