Provider Demographics
NPI:1649236852
Name:BISE, ROGER NEAL (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:NEAL
Last Name:BISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 S 74TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5170
Mailing Address - Country:US
Mailing Address - Phone:479-478-8555
Mailing Address - Fax:
Practice Address - Street 1:2713 S 74TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5170
Practice Address - Country:US
Practice Address - Phone:479-478-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-80722086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148093002Medicaid
AR17633000000OtherQUALCHOICE
P00702260OtherRAILROAD MEDICARE
AR17633000000OtherQUALCHOICE
D16871Medicare UPIN