MEDICARE: INIS JANE BARDELLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	E-12712	AR
2	207Q00000X	Family Medicine Physician	036129581	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	036129581	OTHER	IL	ILLINOIS PHYSICIAN LICENSE

General Provider Information

NPI Number	:	1124084926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INIS JANE BARDELLA M.D.

Provider Business Mailing Address
First Line	:	4021 W 8TH ST
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72204-2029
Country	:	US
Telephone Number	:	501-686-5021
Fax Number	:

Provider Business Practice Location Address
First Line	:	1617 N WASHINGTON
Second Line	:
City	:	MAGNOLIA
State	:	AR
Zip	:	71753-2046
Country	:	US
Telephone Number	:	870-562-2588
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	10/27/2023

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