Basic Information
Provider Information | |||||||||
NPI: | 1356319123 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLYARD | ||||||||
FirstName: | KEITH | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11230 | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729171230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797096700 | ||||||||
FaxNumber: | 4797096730 | ||||||||
Practice Location | |||||||||
Address1: | 3501 W. E. KNIGHT DRIVE | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729037994 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797096700 | ||||||||
FaxNumber: | 4797096730 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 06/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | C7460 | AR | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 18030000000 | 01 | AR | QUALCHOICE | OTHER | 100024370A | 01 | OK | OKLAHOMA MEDICAID | OTHER | 0920103 | 01 | AR | UNITED HEALTHCARE | OTHER | 5160690 | 01 | AR | AETNA | OTHER | 200038806 | 01 | AR | RAILROAD MEDICARE | OTHER | 3117278 | 01 | AR | CIGNA | OTHER | 5K982 | 01 | AR | ARKANSAS BLUE CROSS | OTHER | 138844001 | 05 | AR |   | MEDICAID | 904213 | 01 | AR | USA MCO | OTHER |