Basic Information
Provider Information | |||||||||
NPI: | 1619937745 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOPAEDICS PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RIVER VALLEY MUSCULOSKELETAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11230 | ||||||||
Address2: | 3501 W. E. KNIGHT DRIVE | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729171230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797096767 | ||||||||
FaxNumber: | 4797096768 | ||||||||
Practice Location | |||||||||
Address1: | 3501 WE KNIGHT DR | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729036248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797096700 | ||||||||
FaxNumber: | 4797096768 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2006 | ||||||||
LastUpdateDate: | 10/03/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOLYARD | ||||||||
AuthorizedOfficialFirstName: | KEITH | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4797096700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D.. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1326160001 | 01 | AR | CIGNA GOVERNMENT | OTHER | 100756920A | 05 | OK |   | MEDICAID | 140859002 | 05 | AR |   | MEDICAID | CH0845 | 01 |   | RAILROAD MEDICARE | OTHER |