1174520258 NPI number — DR. TIMOTHY E FREYALDENHOVEN MD

Table of content: DR. TIMOTHY E FREYALDENHOVEN MD (NPI 1174520258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174520258 NPI number — DR. TIMOTHY E FREYALDENHOVEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREYALDENHOVEN
Provider First Name:
TIMOTHY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174520258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 ADA AVE STE 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72034-4985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-932-0352
Provider Business Mailing Address Fax Number:
501-932-0354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 ADA AVE STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72034-4985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-932-0352
Provider Business Practice Location Address Fax Number:
501-932-0354
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  E-3108 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 146351001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130025088 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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