Provider Demographics
NPI:1003882747
Name:BENTONVILLE RADIOLOGY CONSULTANTS, PLLC
Entity Type:Organization
Organization Name:BENTONVILLE RADIOLOGY CONSULTANTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:JONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-392-1706
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1029
Mailing Address - Country:US
Mailing Address - Phone:918-392-1706
Mailing Address - Fax:918-664-6120
Practice Address - Street 1:3000 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3217
Practice Address - Country:US
Practice Address - Phone:479-553-1000
Practice Address - Fax:918-664-6120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F285OtherARK. BCBS
AR156414002Medicaid
AR5F285Medicare PIN