MEDICARE: DR. ALTIMUS RAY BOLLEN 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	207R00000X	Internal Medicine Physician	C6072	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00046	OTHER	AR	NOVASYS
2	5401027	OTHER	AR	AETNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	12692000000	OTHER	AR	QUALCHOICE
5	9292900	OTHER	AR	CIGNA
6	277387	OTHER	AR	HEALTHLINK
7	MG38450	OTHER	AR	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1720054125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALTIMUS RAY BOLLEN M.D.

Provider Business Mailing Address
First Line	:	11001 EXECUTIVE CENTER DR
Second Line	:	SUITE 200
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-4316
Country	:	US
Telephone Number	:	501-812-7587
Fax Number	:	501-812-7777

Provider Business Practice Location Address
First Line	:	1002 SCHNEIDER DR
Second Line	:	SUITE 104
City	:	MALVERN
State	:	AR
Zip	:	72104-4816
Country	:	US
Telephone Number	:	501-337-9066
Fax Number	:	501-332-5265

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

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	05/22/2008

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