Healthcare Provider Details

I. General information

NPI: 1578759965
Provider Name (Legal Business Name): TIMOTHY EWING BAINUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2673 HIGHWAY 70 E
GLENWOOD AR
71943-8750
US

IV. Provider business mailing address

2673 HIGHWAY 70 E
GLENWOOD AR
71943-8750
US

V. Phone/Fax

Practice location:
  • Phone: 870-356-4240
  • Fax: 870-356-4250
Mailing address:
  • Phone: 870-356-4240
  • Fax: 870-356-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberN-5630
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: