Healthcare Provider Details

I. General information

NPI: 1528552130
Provider Name (Legal Business Name): BLAYNE ELLIS BEENE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 LITTLE CREEK CUT OFF RD
SHERIDAN AR
72150-7798
US

IV. Provider business mailing address

342 HIGHWAY 425 S
MONTICELLO AR
71655-4612
US

V. Phone/Fax

Practice location:
  • Phone: 870-942-3000
  • Fax: 870-942-3005
Mailing address:
  • Phone: 870-942-3000
  • Fax: 870-942-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27265
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-14603
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: