Basic Information
Provider Information | |||||||||
NPI: | 1679890966 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WASHINGTON REGIONAL MEDICAL SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WALKER HEART INSTITUTE CARDIOVASCULAR CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12 E APPLEBY RD | ||||||||
Address2: | CLINIC ADMINISTRATION | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727033901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794631704 | ||||||||
FaxNumber: | 4794637864 | ||||||||
Practice Location | |||||||||
Address1: | 3211 N NORTHHILLS BLVD | ||||||||
Address2: | SUITE 110 | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727034007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4795714338 | ||||||||
FaxNumber: | 4795714015 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2010 | ||||||||
LastUpdateDate: | 04/26/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ECKELS | ||||||||
AuthorizedOfficialFirstName: | DANIEL | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VP/CFO | ||||||||
AuthorizedOfficialTelephone: | 4794636026 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.