MEDICARE: MELLOY CONCIERGE AND AESTHETICS MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1184311342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELLOY CONCIERGE AND AESTHETICS MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 3013
Second Line	:
City	:	BELLA VISTA
State	:	AR
Zip	:	72715-0013
Country	:	US
Telephone Number	:	479-278-7010
Fax Number	:	479-974-2009

Provider Business Practice Location Address
First Line	:	200 S 20TH ST STE C
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-1100
Country	:	US
Telephone Number	:	479-278-7010
Fax Number	:	479-974-2009

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JONALEE FORTINER
Credential	:
Telephone Number	:	479-435-4207

Provider Enumeration Date	:	04/19/2023
Last Update Date	:	06/10/2026

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Directions to “MELLOY CONCIERGE AND AESTHETICS MEDICAL GROUP ” Practice Location

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