Provider Demographics
NPI:1053375857
Name:FISH, TED J (MD)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:J
Last Name:FISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3211 N NORTHHILLS BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4007
Mailing Address - Country:US
Mailing Address - Phone:479-571-4338
Mailing Address - Fax:479-571-4015
Practice Address - Street 1:3211 N NORTHHILLS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4007
Practice Address - Country:US
Practice Address - Phone:479-571-4338
Practice Address - Fax:479-571-4015
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN6731207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106458001Medicaid
AR1670493OtherUNITED HEALTHCARE
AR4574734OtherAETNA
ARA012OtherCHAMPUS
ARN6731OtherSTATE LICENSE
OK100177890AMedicaid
AR122040000OtherQUALCHOICE
MO204813208Medicaid
MO204813208Medicaid
AR106458001Medicaid
AR060051129Medicare PIN
AR1670493OtherUNITED HEALTHCARE