Provider Demographics
NPI:1558445080
Name:INFECTIOUS DISEASE SPECIALISTS OF NORTHWEST ARKANSAS
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE SPECIALISTS OF NORTHWEST ARKANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:HALL
Authorized Official - Last Name:HENNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-444-6522
Mailing Address - Street 1:4038 N REMINGTON DR STE 4
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6314
Mailing Address - Country:US
Mailing Address - Phone:479-444-6522
Mailing Address - Fax:479-444-9426
Practice Address - Street 1:4038 N REMINGTON DR STE 4
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6314
Practice Address - Country:US
Practice Address - Phone:479-444-6522
Practice Address - Fax:479-444-9426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0104174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F046OtherBLUE CROSS
AR125127001Medicaid
AR5F046Medicare ID - Type Unspecified
AR5F046OtherBLUE CROSS