Provider Demographics
NPI:1740550805
Name:S. THOMAS RAYBURN III, MD, P.A.
Entity type:Organization
Organization Name:S. THOMAS RAYBURN III, MD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:RAYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-223-5757
Mailing Address - Street 1:9601 BAPTIST HEALTH DR
Mailing Address - Street 2:STE. 570
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6321
Mailing Address - Country:US
Mailing Address - Phone:501-223-5757
Mailing Address - Fax:501-223-5758
Practice Address - Street 1:9601 BAPTIST HEALTH DR
Practice Address - Street 2:STE. 570
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6321
Practice Address - Country:US
Practice Address - Phone:501-223-5757
Practice Address - Fax:501-223-5758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2209208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137308001Medicaid
AR5L189Medicare UPIN