Healthcare Provider Details

I. General information

NPI: 1093178915
Provider Name (Legal Business Name): RYAN MICHAEL SOUTHARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 HOGAN LN STE 500
CONWAY AR
72034-7970
US

IV. Provider business mailing address

821 HOGAN LN STE 500
CONWAY AR
72034-7970
US

V. Phone/Fax

Practice location:
  • Phone: 501-764-4443
  • Fax: 501-764-4454
Mailing address:
  • Phone: 501-764-4443
  • Fax: 501-358-9894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-12104
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82349
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: