Provider Demographics
NPI:1457525933
Name:GARRY STEWART MD PA
Entity type:Organization
Organization Name:GARRY STEWART MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-513-1225
Mailing Address - Street 1:P.O. BOX 11349
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-1349
Mailing Address - Country:US
Mailing Address - Phone:501-513-1225
Mailing Address - Fax:501-513-1228
Practice Address - Street 1:1545 HOGAN LANE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-1349
Practice Address - Country:US
Practice Address - Phone:501-513-1225
Practice Address - Fax:501-513-1228
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARRY STEWART MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-16
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154599001Medicaid
AR154599002Medicaid