Basic Information
| Provider Information | |||||||||
| NPI: | 1184882383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLYLE | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | WAGNER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3150 E HERITAGE PKWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727305529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794001140 | ||||||||
| FaxNumber: | 4794001151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2008 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-7051 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | E-7051 | AR | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | E-7051 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 190430001 | 05 | AR | MEDICAID |