1073636551 NPI number — WADE FALWELL, M.D.,P.A.

Table of content: (NPI 1073636551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073636551 NPI number — WADE FALWELL, M.D.,P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WADE FALWELL, M.D.,P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073636551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 MCLAIN ST
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72112-3661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-523-3053
Provider Business Mailing Address Fax Number:
870-523-3637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 MCLAIN ST
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72112-3661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-523-3053
Provider Business Practice Location Address Fax Number:
870-523-3637
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FALWELL
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
870-523-3053

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  207Q00000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 117464002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114224001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1458600000 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 080017871 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 50313 . This is a "ARKANSAS BLUECROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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