Basic Information
| Provider Information | |||||||||
| NPI: | 1821074592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENDLEY | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127215 | ||||||||
| FaxNumber: | 5018127207 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 SPRINGHILL DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721172949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019555589 | ||||||||
| FaxNumber: | 5019555960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 03/23/2018 | ||||||||
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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 | 207Q00000X | C4596 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0505X | C4596 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QG0300X | C4596 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207RE0101X | C4596 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0300X | C4596 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | C4596 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0420289 | 01 | AR | UNITED HEALTHCARE ID | OTHER | 110190362 | 01 | AR | RR MCARE PROVIDER ID | OTHER | 11306000000 | 01 | AR | QUALCHOICE PROVIDER ID | OTHER | 106701001 | 05 | AR | MEDICAID | 4234056 | 01 | AR | AETNA PROVIDER ID | OTHER |