Provider Demographics
NPI:1932168606
Name:PEDIATRIC PARTNERS PA
Entity Type:Organization
Organization Name:PEDIATRIC PARTNERS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-478-7200
Mailing Address - Street 1:PO BOX 11017
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1017
Mailing Address - Country:US
Mailing Address - Phone:479-478-7200
Mailing Address - Fax:479-478-7225
Practice Address - Street 1:7303 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4112
Practice Address - Country:US
Practice Address - Phone:479-478-7200
Practice Address - Fax:479-478-7225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC2365208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F086OtherBLUE CROSS & BLUE SHIELD
AR5F086OtherBLUE CROSS & BLUE SHIELD