1629311253 NPI number — WHITE COUNTY MEDICAL CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629311253 NPI number — WHITE COUNTY MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE COUNTY MEDICAL CENTER
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:
WESTSIDE FAMILY MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1629311253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 WOODLANE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEARCY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72143-6113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-268-3733
Provider Business Mailing Address Fax Number:
501-207-6139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 WOODLANE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEARCY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72143-6113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-268-3733
Provider Business Practice Location Address Fax Number:
501-207-6139
Provider Enumeration Date:
04/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HILL
Authorized Official First Name:
STUART
Authorized Official Middle Name:
R
Authorized Official Title or Position:
VP, TREASURER
Authorized Official Telephone Number:
501-380-1004

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , 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: 199942002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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