NPIMap

Organization Active NPI

Ophthalmology Associates of Benton, PLLC

  • Specialist
  • Benton, AR
National Provider Identifier
1699774794
Registry record updated Sep 30, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
C7930 Issued in AR
Legal business name
OPHTHALMOLOGY ASSOCIATES OF BENTON, PLLC
Practice address
3 Medical Park Dr
Suite 300
Benton, AR 72015-3728
Phone
(501) 778-1113
Fax
(501) 778-5391
NPI assigned
Jul 20, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 30, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Linda Detherage
Title
Insurance & Credentialing
Phone
(501) 778-1113

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 174400000X C7930 AR Primary
SpecialistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 174400000X C7476 AR
SpecialistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 174400000X E-2274 AR

Addresses

Primary practice location

3 Medical Park Dr
Suite 300
Benton, AR 72015-3728

Mailing address

3 Medical Park Dr
Suite 300
Benton, AR 72015-3728
Phone (501) 778-1113

Other identifiers 3

IdentifierTypeStateIssuer
5B790OtherARBLUE CROSS BLUE SHIELD
140820002MedicaidAR
CI3712OtherARRAILROAD MEDICARE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20080125000654 AR Part B Supplier - Clinic/Group Practice 3971685132 Receives reassigned benefits from 2 practitioners
Practice locations: Benton, AR
O20100930091654 AR DME Supplier - Physician - Ophthalmology 3971685132 Practice locations: Benton, AR

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121817600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1380499200000",
    "number": "1699774794",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3 MEDICAL PARK DR",
            "address_2": "SUITE 300",
            "city": "BENTON",
            "state": "AR",
            "postal_code": "720153728",
            "telephone_number": "501-778-1113",
            "fax_number": "501-778-5391"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3 MEDICAL PARK DR",
            "address_2": "SUITE 300",
            "city": "BENTON",
            "state": "AR",
            "postal_code": "720153728",
            "telephone_number": "501-778-1113",
            "fax_number": "501-778-5391"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OPHTHALMOLOGY ASSOCIATES OF BENTON, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-20",
        "last_updated": "2013-09-30",
        "status": "A",
        "authorized_official_last_name": "DETHERAGE",
        "authorized_official_first_name": "LINDA",
        "authorized_official_title_or_position": "INSURANCE & CREDENTIALING",
        "authorized_official_telephone_number": "501-778-1113",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "AR",
            "license": "C7930",
            "primary": true
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "AR",
            "license": "C7476",
            "primary": false
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "AR",
            "license": "E-2274",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "5B790",
            "state": "AR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "140820002",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CI3712",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Benton, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 30, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.