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NPI Code Detail

MEDICARE: GARY M PETRUS MD PA

MEDICARE: GARY M PETRUS MD PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12086S0122XPlastic and Reconstructive Surgery PhysicianC7318AR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1871666446
Entity Type Code : Organization
Provider Name (Legal Business Name) : GARY M PETRUS MD PA
Provider Business Mailing Address
First Line : 2504 MCCAIN BLVD
Second Line : SUITE 114
City : NORTH LITTLE ROCK
State : AR
Zip : 72116-7624
Country : US
Telephone Number : 501-758-9800
Fax Number : 501-758-0199
Provider Business Practice Location Address
First Line : 2504 MCCAIN BLVD
Second Line : SUITE 114
City : NORTH LITTLE ROCK
State : AR
Zip : 72116-7624
Country : US
Telephone Number : 501-758-9800
Fax Number : 501-758-0199
Authorized Official
Title or Position : PRESIDENT
Name : DR. GARY MICHAEL PETRUS
Credential : MD
Telephone Number : 501-758-9800
Provider Enumeration Date : 11/15/2006
Last Update Date : 01/28/2011

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