Basic Information
| Provider Information | |||||||||
| NPI: | 1477718179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WASHINGTON REGIONAL MEDICAL SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WASHINGTON REGIONAL RADIOLOGY | ||||||||
| 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: | 3215 N NORTHHILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799688279 | ||||||||
| FaxNumber: | 4799684331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | ECKLES | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4794637775 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 155590002 | 05 | AR | MEDICAID |