Provider Demographics
NPI:1841381662
Name:ROGER N. BISE, MD PA
Entity type:Organization
Organization Name:ROGER N. BISE, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:BISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-478-8555
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC21852086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148093002Medicaid
AR17633000000OtherQUALCHOICE
CK2325OtherRAILROAD MEDICARE
AR17633000000OtherQUALCHOICE