MEDICARE: PEDIATRIC PARTNERS PA

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	MC2365	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5F086	OTHER	AR	BLUE CROSS & BLUE SHIELD

General Provider Information

NPI Number	:	1932168606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC PARTNERS PA

Provider Business Mailing Address
First Line	:	PO BOX 11017
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72917-1017
Country	:	US
Telephone Number	:	479-478-7200
Fax Number	:	479-478-7225

Provider Business Practice Location Address
First Line	:	7303 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-4112
Country	:	US
Telephone Number	:	479-478-7200
Fax Number	:	479-478-7225

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JON R HENDRICKSON
Credential	:	MD
Telephone Number	:	479-478-7200

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

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Practice Location Address:

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1316432024 — ANDRES DAVID PIRELA ARAQUE MD
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Directions to “PEDIATRIC PARTNERS PA ” Practice Location

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