Basic Information
| Provider Information | |||||||||
| NPI: | 1447281670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BENTONVILLE ANESTHESIA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 756 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727450756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476152200 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727123217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795634368 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | HAYS | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8476152200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 5F200 | 01 | AR | BCBS OF ARKANSAS | OTHER |