=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871553073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST BENTON COUNTY PHYSICIAN SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2006
-----------------------------------------------------
Last Update Date | 05/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1102 NW LOWES AVE STE 2
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-4978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-254-8563
-----------------------------------------------------
Fax | 479-254-8564
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 689022
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37068-9022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-465-7385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR PROVIDER ENROLLMENT
-----------------------------------------------------
Name | KRISTINA MUSIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-892-9815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------