Healthcare Provider Details

I. General information

NPI: 1194789685
Provider Name (Legal Business Name): JERRY DOUGLAS BYRUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 AUTUMN RD SUITE 100
LITTLE ROCK AR
72211-3742
US

IV. Provider business mailing address

904 AUTUMN RD SUITE 100
LITTLE ROCK AR
72211-3742
US

V. Phone/Fax

Practice location:
  • Phone: 501-224-5437
  • Fax: 501-224-3473
Mailing address:
  • Phone: 501-224-5437
  • Fax: 501-224-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC6800
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: