Healthcare Provider Details

I. General information

NPI: 1457396780
Provider Name (Legal Business Name): LITTLE ROCK PEDIATRIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S UNIVERSITY AVE STE 615
LITTLE ROCK AR
72205-5308
US

IV. Provider business mailing address

500 S UNIVERSITY AVE STE 615
LITTLE ROCK AR
72205-5308
US

V. Phone/Fax

Practice location:
  • Phone: 501-664-4044
  • Fax: 501-664-4064
Mailing address:
  • Phone: 501-664-4044
  • Fax: 501-664-4064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JO LYNNE VARNER
Title or Position: ADMINISTRATOR
Credential: MHSA
Phone: 501-664-4044