=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720054125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALTIMUS RAY BOLLEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2006
-----------------------------------------------------
Last Update Date | 05/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 SCHNEIDER DR SUITE 104
-----------------------------------------------------
City | MALVERN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72104-4816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-337-9066
-----------------------------------------------------
Fax | 501-332-5265
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11001 EXECUTIVE CENTER DR SUITE 200
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-812-7587
-----------------------------------------------------
Fax | 501-812-7777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | C6072
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------