Provider Demographics
NPI:1699737239
Name:INTERNAL MEDICINE ASSOCIATES OF BENTON, P.A.
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF BENTON, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GALA
Authorized Official - Middle Name:C
Authorized Official - Last Name:TALLENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-778-5740
Mailing Address - Street 1:112 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3765
Mailing Address - Country:US
Mailing Address - Phone:501-778-5740
Mailing Address - Fax:501-778-5743
Practice Address - Street 1:112 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3765
Practice Address - Country:US
Practice Address - Phone:501-778-5740
Practice Address - Fax:501-778-5743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57662Medicare ID - Type Unspecified