Basic Information
| Provider Information | |||||||||
| NPI: | 1477542793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNING | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | JEFFERY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S UNIVERSITY AVE | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016643914 | ||||||||
| FaxNumber: | 5016645246 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S UNIVERSITY AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016643914 | ||||||||
| FaxNumber: | 5016645246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | E0829 | AR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 136011001 | 05 | AR | MEDICAID |