Provider Demographics
NPI:1497812903
Name:SURGICAL ASSOCIATES OF BENTON
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES OF BENTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-778-3361
Mailing Address - Street 1:3 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3728
Mailing Address - Country:US
Mailing Address - Phone:501-778-3361
Mailing Address - Fax:501-778-3135
Practice Address - Street 1:3 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3728
Practice Address - Country:US
Practice Address - Phone:501-778-3361
Practice Address - Fax:501-778-3135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0173174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARF86661Medicare UPIN
AR5C644Medicare ID - Type Unspecified