Basic Information
| Provider Information | |||||||||
| NPI: | 1760432629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WASHINGTON REGIONAL MEDICAL SYSTEM | ||||||||
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| OtherOrganizationName: | HERHEALTH BY WASHINGTON REGIONAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 E APPLEBY RD | ||||||||
| Address2: | CLINICS ADMINISTRATION | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727033901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794631704 | ||||||||
| FaxNumber: | 4794637864 | ||||||||
| Practice Location | |||||||||
| Address1: | 3215 N NORTH HILLS BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794635500 | ||||||||
| FaxNumber: | 4794635542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | WILEY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, SYSTEMS CLINICS | ||||||||
| AuthorizedOfficialTelephone: | 4794631390 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 111898002 | 05 | AR | MEDICAID |