Provider Demographics
NPI:1871666446
Name:GARY M PETRUS MD PA
Entity Type:Organization
Organization Name:GARY M PETRUS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PETRUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-758-9800
Mailing Address - Street 1:2504 MCCAIN BLVD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7624
Mailing Address - Country:US
Mailing Address - Phone:501-758-9800
Mailing Address - Fax:501-758-0199
Practice Address - Street 1:2504 MCCAIN BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7624
Practice Address - Country:US
Practice Address - Phone:501-758-9800
Practice Address - Fax:501-758-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC73182086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR114482001Medicaid
AR122380002Medicaid
5C035Medicare ID - Type UnspecifiedGROUP
D04406Medicare UPIN
50767Medicare ID - Type UnspecifiedINDIVIDUAL