Provider Demographics
NPI:1023372208
Name:PLASTIC SURGERY CENTER OF NWA, P.A.
Entity Type:Organization
Organization Name:PLASTIC SURGERY CENTER OF NWA, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-464-9191
Mailing Address - Street 1:2900 MEDICAL CENTER PKWY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3204
Mailing Address - Country:US
Mailing Address - Phone:479-464-9191
Mailing Address - Fax:479-464-8840
Practice Address - Street 1:2900 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 220
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3204
Practice Address - Country:US
Practice Address - Phone:479-464-9191
Practice Address - Fax:479-464-8840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3659208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F30806Medicare UPIN