=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841218617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRANT BENNETT M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 12/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 E DAVE WARD DR
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032-7825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-500-3500
-----------------------------------------------------
Fax | 501-904-3620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 FAIR PARK BLVD
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72204-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-404-8007
-----------------------------------------------------
Fax | 501-904-3620
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | E7329
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | LL29147
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------