Basic Information
| Provider Information | |||||||||
| NPI: | 1720054125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLLEN | ||||||||
| FirstName: | ALTIMUS | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLLEN | ||||||||
| OtherFirstName: | RAY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127587 | ||||||||
| FaxNumber: | 5018127777 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 SCHNEIDER DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MALVERN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721044816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013379066 | ||||||||
| FaxNumber: | 5013325265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | C6072 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00046 | 01 | AR | NOVASYS | OTHER | 5401027 | 01 | AR | AETNA | OTHER | 102657001 | 05 | AR | MEDICAID | 12692000000 | 01 | AR | QUALCHOICE | OTHER | 9292900 | 01 | AR | CIGNA | OTHER | 277387 | 01 | AR | HEALTHLINK | OTHER | MG38450 | 01 | AR | UNITED HEALTHCARE | OTHER |