Healthcare Provider Details

I. General information

NPI: 1609251842
Provider Name (Legal Business Name): PEDIATRIC PHYSICIANS GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S UNIVERSITY AVE SUITE 200
LITTLE ROCK AR
72205-5302
US

IV. Provider business mailing address

500 S UNIVERSITY AVE SUITE 200
LITTLE ROCK AR
72205-5302
US

V. Phone/Fax

Practice location:
  • Phone: 501-664-4117
  • Fax: 501-664-1137
Mailing address:
  • Phone: 501-664-4117
  • Fax: 501-664-1137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ANTHONY D JOHNSON
Title or Position: MBR
Credential: MD
Phone: 501-664-4117