Healthcare Provider Details

I. General information

NPI: 1710365382
Provider Name (Legal Business Name): MARY ANNETTE PUGH MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HIGHWAY 65 S
CLINTON AR
72031-6588
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 479-979-8064
  • Fax: 479-219-5500
Mailing address:
  • Phone: 800-824-4094
  • Fax: 479-968-1643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY PUGH
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 479-806-4290