Basic Information
| Provider Information | |||||||||
| NPI: | 1427149814 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITE RIVER HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STONE COUNTY MEDICAL CENTER ER CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 510 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725600510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702694361 | ||||||||
| FaxNumber: | 8702693093 | ||||||||
| Practice Location | |||||||||
| Address1: | 2106 E. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725606439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702625056 | ||||||||
| FaxNumber: | 8702626088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 03/06/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8702621440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITE RIVER HEALTH SYSTEM, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | N | Hospitals | General Acute Care Hospital | Critical Access | 207PE0004X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 157571105 | 05 | AR | MEDICAID | 57891 | 01 | AR | BCBS | OTHER | 112094002 | 05 | AR | MEDICAID |