1639282197 NPI number — WASHINGTON REGIONAL MEDICAL SYSTEM

Table of content: (NPI 1639282197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639282197 NPI number — WASHINGTON REGIONAL MEDICAL SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHINGTON REGIONAL MEDICAL SYSTEM
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:
WEST WASHINGTON COUNTY CLINIC WASHINGTON REGIONAL
Provider Other Organization Name Type Code:
5
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:
1639282197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWELL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72745-0550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-463-7775
Provider Business Mailing Address Fax Number:
479-463-7187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 EAST PARK STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-824-3196
Provider Business Practice Location Address Fax Number:
479-267-4397
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ECKELS
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
479-463-2825

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 131551002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG1875 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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