Provider Demographics
NPI:1356319123
Name:BOLYARD, KEITH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:J
Last Name:BOLYARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 11230
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1230
Mailing Address - Country:US
Mailing Address - Phone:479-709-6700
Mailing Address - Fax:479-709-6730
Practice Address - Street 1:3501 W. E. KNIGHT DRIVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-7994
Practice Address - Country:US
Practice Address - Phone:479-709-6700
Practice Address - Fax:479-709-6730
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7460207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18030000000OtherQUALCHOICE
OK100024370AOtherOKLAHOMA MEDICAID
AR0920103OtherUNITED HEALTHCARE
AR5160690OtherAETNA
AR200038806OtherRAILROAD MEDICARE
AR3117278OtherCIGNA
AR5K982OtherARKANSAS BLUE CROSS
AR138844001Medicaid
AR904213OtherUSA MCO
AR5K982Medicare PIN
AR138844001Medicaid
OK242732308Medicare PIN