Basic Information
| Provider Information | |||||||||
| NPI: | 1861504409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETITE ROCHE EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 MAIN ST | ||||||||
| Address2: | SUITE 5200 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2147122000 | ||||||||
| FaxNumber: | 2147122487 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 SAINT VINCENT CIR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016645360 | ||||||||
| FaxNumber: | 2147122487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 21471224000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5F619 | 01 | AR | BLUE SHIELD | OTHER |