| NPI |
1093100976 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
| Entity Type Code |
1 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Provider Last Name Legal Name |
ITTLEMAN |
The last name of the provider. If the provider is an individual, this is the legal name. |
| Provider First Name |
BENJAMIN |
The first name of the provider, if the provider
is an individual. |
| Provider Middle Name |
R |
The middle name of the provider, if the provider
is an individual. |
| Provider Credential Text |
M.D. |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
| Provider First Line Business Practice Location Address |
1 CHILDRENS WAY # 512-1 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name |
LITTLE ROCK |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
AR |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Provider Business Practice Location Address Postal Code |
722023500 |
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider Business Practice Location Address Telephone Number |
5013643418 |
Other name by which the organization provider is or has been known. |
| Provider Business Practice Location Address Fax Number |
5013645262 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
| Provider Enumeration Date |
3/30/2015 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Last Update Date |
9/18/2023 |
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
| Provider Gender Code |
M |
The city name in the location address of the provider being identified. |
| Healthcare Provider Taxonomy Code 1 |
208000000X |
The State code in the location of the provider
being identified. |
| Provider License Number 1 |
E-16679 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider License Number State Code 1 |
AR |
The country code in the location address of the provider being identified. |
| Healthcare Provider Primary Taxonomy Switch 1 |
N |
The telephone number associated with the location address of the provider being identified. |
| Healthcare Provider Taxonomy Code 2 |
208000000X |
The fax number associated with the location
address of the provider being identified. |
| Provider License Number 2 |
042.0014072 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Provider License Number State Code 2 |
VT |
The date that a record was last updated or changed. |
| Healthcare Provider Primary Taxonomy Switch 2 |
N |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Healthcare Provider Taxonomy Code 3 |
2080P0202X |
|
| Provider License Number 3 |
MD61304160 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 3 |
WA |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Healthcare Provider Primary Taxonomy Switch 3 |
N |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 4 |
2080P0202X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider License Number 4 |
E-16679 |
|
| Provider License Number State Code 4 |
AR |
|
| Healthcare Provider Primary Taxonomy Switch 4 |
Y |
|
| Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| NPI Certification Date |
9/18/2023 |
|