1881859593 NPI number — CORWIN D. PETTY, MD, PA

Table of content: (NPI 1881859593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881859593 NPI number — CORWIN D. PETTY, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORWIN D. PETTY, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881859593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3201 S MARKET ST STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72758-8168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-254-1005
Provider Business Mailing Address Fax Number:
479-668-4003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 S MARKET ST STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72758-8168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-254-1005
Provider Business Practice Location Address Fax Number:
479-668-4003
Provider Enumeration Date:
07/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PETTY
Authorized Official First Name:
CORWIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER / PHYSICIAN
Authorized Official Telephone Number:
479-254-1005

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5C680 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 149427002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com