Healthcare Provider Details

I. General information

NPI: 1285254193
Provider Name (Legal Business Name): GLENWOOD PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 N 1ST ST STE C
GLENWOOD AR
71943-9252
US

IV. Provider business mailing address

408 N 1ST ST STE C
GLENWOOD AR
71943-9252
US

V. Phone/Fax

Practice location:
  • Phone: 870-356-2288
  • Fax:
Mailing address:
  • Phone: 870-356-1556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LOREN DEPUTY
Title or Position: OWNER
Credential: MD
Phone: 870-356-1556