MEDICARE: PEDIATRIC ASSOCIATES OF JONESBORO, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MC-2201	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5C645	OTHER	AR	BLUE CROSS NUMBER

General Provider Information

NPI Number	:	1134121635
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC ASSOCIATES OF JONESBORO, PLLC

Provider Business Mailing Address
First Line	:	1150 E MATTHEWS AVE
Second Line	:	SUITE 101
City	:	JONESBORO
State	:	AR
Zip	:	72401-4314
Country	:	US
Telephone Number	:	870-972-5437
Fax Number	:	870-972-0104

Provider Business Practice Location Address
First Line	:	1150 E MATTHEWS AVE
Second Line	:	SUITE 101
City	:	JONESBORO
State	:	AR
Zip	:	72401-4314
Country	:	US
Telephone Number	:	870-972-5437
Fax Number	:	870-972-0104

Authorized Official
Title or Position	:	MEMEBER
Name	:	RICHARD M REINHARD III
Credential	:	M.D.
Telephone Number	:	870-972-5437

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	07/16/2007

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