Healthcare Provider Details

I. General information

NPI: 1205687217
Provider Name (Legal Business Name): KID GLOVES SURGICAL SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 JOHNSON MILL BLVD STE 101
SPRINGDALE AR
72762-6412
US

IV. Provider business mailing address

PO BOX 6908
SPRINGDALE AR
72766-6908
US

V. Phone/Fax

Practice location:
  • Phone: 501-349-3182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCENE R MCVAY GILLAM
Title or Position: OWNER/MANAGER
Credential: MD
Phone: 501-349-3182