Provider Demographics
NPI:1861859704
Name:BENTONVILLE MEDICAL ARTS PLLC
Entity Type:Organization
Organization Name:BENTONVILLE MEDICAL ARTS PLLC
Other - Org Name:LANCE L HAMILTON M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-414-6283
Mailing Address - Street 1:2618 SE J STREET
Mailing Address - Street 2:STE 12
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-715-6505
Mailing Address - Fax:479-340-0015
Practice Address - Street 1:2618 SE J STREET
Practice Address - Street 2:STE 12
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:479-715-6505
Practice Address - Fax:479-340-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8166207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100125440AMedicaid
AR121148801Medicaid
AR121148801Medicaid
ARE99124Medicare UPIN