Basic Information
| Provider Information | |||||||||
| NPI: | 1710233010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITE RIVER HEALTH SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STONE COUNTY ANESTHESIA GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2106 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725606439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702694361 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2106 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725606439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702694361 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2012 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | BEBOW | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8702626091 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STONE COUNTY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 112094002 | 05 | AR | MEDICAID |