Provider Demographics
NPI:1457396780
Name:LITTLE ROCK PEDIATRIC GROUP
Entity Type:Organization
Organization Name:LITTLE ROCK PEDIATRIC GROUP
Other - Org Name:LITTLE ROCK PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:VARNER
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:501-664-4044
Mailing Address - Street 1:500 S UNIVERSITY AVE STE 615
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5308
Mailing Address - Country:US
Mailing Address - Phone:501-664-4044
Mailing Address - Fax:501-664-4064
Practice Address - Street 1:500 S UNIVERSITY AVE STE 615
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5308
Practice Address - Country:US
Practice Address - Phone:501-664-4044
Practice Address - Fax:501-664-4064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145428002Medicaid