1538446323 NPI number — BINGHAM MD LLC

Table of content: (NPI 1538446323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538446323 NPI number — BINGHAM MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BINGHAM MD LLC
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:
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:
1538446323
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72766-6220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-287-4370
Provider Business Mailing Address Fax Number:
479-287-4586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5230 WILLOW CREEK DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SPRINGDALE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72762-0876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-287-4370
Provider Business Practice Location Address Fax Number:
479-287-4586
Provider Enumeration Date:
11/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BINGHAM
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PHYSICIAN-OWNER
Authorized Official Telephone Number:
479-287-4370

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  E1940 , 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: 135065001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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