Provider Demographics
NPI:1316308570
Name:ROBERT PETRINO, MD, PA
Entity type:Organization
Organization Name:ROBERT PETRINO, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:539-664-7190
Mailing Address - Street 1:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72765-0343
Mailing Address - Country:US
Mailing Address - Phone:539-664-7190
Mailing Address - Fax:479-756-2721
Practice Address - Street 1:706 QUANDT AVE
Practice Address - Street 2:STE A
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764
Practice Address - Country:US
Practice Address - Phone:479-757-2030
Practice Address - Fax:479-750-6236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5439208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR214698002Medicaid