=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861054181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAJA HASSAN IMTIAZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2019
-----------------------------------------------------
Last Update Date | 09/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 HARRISON ST STE T
-----------------------------------------------------
City | BATESVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72501-7315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-262-6155
-----------------------------------------------------
Fax | 870-262-6512
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 HARRISON ST
-----------------------------------------------------
City | BATESVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72501-7303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-262-6155
-----------------------------------------------------
Fax | 870-262-6512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | E-17096
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | E17096
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------