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General NPI Number Information
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NPI Number | 1558445080
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Entity Type | Organization
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Legal Business Name | INFECTIOUS DISEASE SPECIALISTS OF NORTHWEST ARKANSAS
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 04/08/2011
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Provider Practice Location Address
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Address Line | 4038 N REMINGTON DR STE 4
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-6314
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Country | US
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Telephone | 479-444-6522
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Fax | 479-444-9426
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Provider Business Mailing Address
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Address Line | 4038 N REMINGTON DR STE 4
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-6314
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Country | US
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Telephone | 479-444-6522
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Fax | 479-444-9426
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Authorized Official
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Title or Position | OWNER
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Name | STEPHEN HALL HENNIGAN
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Credential | MD
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Telephone | 479-444-6522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | E0104
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License Number State | AR
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