Basic Information
Provider Information | |||||||||
NPI: | 1801882675 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENRY | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 S UNIVERSITY AVE | ||||||||
Address2: | SUITE 505 | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722055307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016644532 | ||||||||
FaxNumber: | 5016634335 | ||||||||
Practice Location | |||||||||
Address1: | 500 S UNIVERSITY AVE | ||||||||
Address2: | SUITE 505 | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722055307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016644532 | ||||||||
FaxNumber: | 5016634335 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2005 | ||||||||
LastUpdateDate: | 12/04/2007 | ||||||||
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 | 207L00000X | C-6619 | AR | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | C-6619 | AR | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 51828 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER | 14974000020 | 01 | AR | QUAL CHOICE (LRPM) | OTHER | S04280 | 01 | AR | NOVASYS | OTHER | 71033532430 | 01 | AR | QUAL CHOICE | OTHER |