Healthcare Provider Details

I. General information

NPI: 1770525594
Provider Name (Legal Business Name): RONDALL KEVIN HANEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5433 WALSH LANE
ROGERS AR
72758
US

IV. Provider business mailing address

5433 W WALSH LN
ROGERS AR
72758-8946
US

V. Phone/Fax

Practice location:
  • Phone: 479-464-8346
  • Fax: 479-464-9046
Mailing address:
  • Phone: 479-464-8346
  • Fax: 479-464-9046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberC-8120
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC-8120
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: