Basic Information
| Provider Information | |||||||||
| NPI: | 1558691410 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAXTER COUNTY REGIONAL HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | BAXTER REGIONAL PEDIATRIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 HOSPITAL DR DEPT 7880 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705081000 | ||||||||
| FaxNumber: | 8705081644 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 HOSPITAL DR DEPT 7880 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705081000 | ||||||||
| FaxNumber: | 8705081644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2009 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8705081003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 182455002 | 05 | AR | MEDICAID |