1790063923 NPI number — BETHEL BURRIS OLIVER PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790063923 NPI number — BETHEL BURRIS OLIVER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHEL BURRIS OLIVER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1790063923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3787 N. FRONT ST.
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-5906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-445-6335
Provider Business Mailing Address Fax Number:
479-301-2878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2606 BROWNS LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-445-6335
Provider Business Practice Location Address Fax Number:
479-301-2878
Provider Enumeration Date:
07/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BURRIS
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-445-6335

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 3465 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , 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: 206261631 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 190787631 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1740449339 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 206304631 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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