Basic Information
| Provider Information | |||||||||
| NPI: | 1861518698 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STUTTGART MEDICAL CLINIC, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1609 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | STUTTGART | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721603274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706737211 | ||||||||
| FaxNumber: | 8706726823 | ||||||||
| Practice Location | |||||||||
| Address1: | 1609 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | STUTTGART | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721603274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706737211 | ||||||||
| FaxNumber: | 8706726823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | LURA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8706746783 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100907002 | 05 | AR | MEDICAID |