Basic Information
| Provider Information | |||||||||
| NPI: | 1033559752 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON REGIONAL MEDICAL SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHILOH CLINIC WASHINGTON REGIONAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727450550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794637775 | ||||||||
| FaxNumber: | 4794637187 | ||||||||
| Practice Location | |||||||||
| Address1: | 513 N SHILOH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727643343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794199902 | ||||||||
| FaxNumber: | 4794199950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2013 | ||||||||
| LastUpdateDate: | 08/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRADLEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4794635007 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.