=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750333795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRINGDALE BENTONVILLE SURGERY CENTER LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 11/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 MEDICAL CENTER PKWY SUITE 100
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-3204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-418-5300
-----------------------------------------------------
Fax | 479-418-5330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 841231
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75284-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-418-5300
-----------------------------------------------------
Fax | 479-418-5330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR BUSINESS OFFICE SUPPORT
-----------------------------------------------------
Name | LAURIE HOLTSFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-465-7466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | AR-4298
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------