1861859704 NPI number — BENTONVILLE MEDICAL ARTS PLLC

Table of content: (NPI 1861859704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861859704 NPI number — BENTONVILLE MEDICAL ARTS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENTONVILLE MEDICAL ARTS PLLC
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:
LANCE L HAMILTON M.D.
Provider Other Organization Name Type Code:
5
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:
1861859704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2618 SE J STREET
Provider Second Line Business Mailing Address:
STE 12
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-715-6505
Provider Business Mailing Address Fax Number:
479-340-0015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2618 SE J STREET
Provider Second Line Business Practice Location Address:
STE 12
Provider Business Practice Location Address City Name:
BENTONVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-715-6505
Provider Business Practice Location Address Fax Number:
479-340-0015
Provider Enumeration Date:
01/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HAMILTON
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-414-6283

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  N8166 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100125440A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121148801 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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