Provider Demographics
NPI:1306877576
Name:NORTH LITTLE ROCK PRIMARY CARE AND DIAGNOSTIC CLINIC PLLC
Entity type:Organization
Organization Name:NORTH LITTLE ROCK PRIMARY CARE AND DIAGNOSTIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-771-7717
Mailing Address - Street 1:400 W PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:N LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-2146
Mailing Address - Country:US
Mailing Address - Phone:501-771-7717
Mailing Address - Fax:501-771-0550
Practice Address - Street 1:400 W PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:N LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-2146
Practice Address - Country:US
Practice Address - Phone:501-771-7717
Practice Address - Fax:501-771-0550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B979OtherBLUE CROSS
AR133705002Medicaid
AR133705002Medicaid