Provider Demographics
NPI:1891018958
Name:BENTON COUNTY UROLOGY, PA
Entity type:Organization
Organization Name:BENTON COUNTY UROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:479-636-9669
Mailing Address - Street 1:200 S 20TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1100
Mailing Address - Country:US
Mailing Address - Phone:479-636-9669
Mailing Address - Fax:479-636-0743
Practice Address - Street 1:200 S 20TH ST STE C
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1100
Practice Address - Country:US
Practice Address - Phone:479-636-9669
Practice Address - Fax:479-636-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4951174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty