Healthcare Provider Details

I. General information

NPI: 1235201112
Provider Name (Legal Business Name): CHICOT MEMORIAL HOSPITAL ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2729 HWY 65 & 82 SOUTH
LAKE VILLAGE AR
71653
US

IV. Provider business mailing address

2729 HWY 65 & 82 SOUTH
LAKE VILLAGE AR
71653
US

V. Phone/Fax

Practice location:
  • Phone: 870-265-5351
  • Fax: 870-265-3910
Mailing address:
  • Phone: 870-265-5351
  • Fax: 870-265-3910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License NumberAR4314
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAR3934
License Number StateAR

VIII. Authorized Official

Name: BRUCE A BENNETT
Title or Position: CEO
Credential:
Phone: 870-265-5351