Healthcare Provider Details

I. General information

NPI: 1346551314
Provider Name (Legal Business Name): THURSTON MATTHEW BAUER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 05/05/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SAINT VINCENT CIR SUITE 501
LITTLE ROCK AR
72205-5412
US

IV. Provider business mailing address

10100 KANIS RD
LITTLE ROCK AR
72205-6202
US

V. Phone/Fax

Practice location:
  • Phone: 501-666-2894
  • Fax: 501-666-9017
Mailing address:
  • Phone: 501-255-6336
  • Fax: 501-255-6409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberE-9804
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: