Healthcare Provider Details

I. General information

NPI: 1952544793
Provider Name (Legal Business Name): RUTHIE SU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

1 CHILDRENS WAY # 844
LITTLE ROCK AR
72202-3500
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-2090
  • Fax: 501-364-3929
Mailing address:
  • Phone: 501-364-2090
  • Fax: 501-364-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number60839
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number60839
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberE17173
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: