Basic Information
| Provider Information | |||||||||
| NPI: | 1962447680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | BILLY | ||||||||
| MiddleName: | KOSSUTH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29001 | ||||||||
| Address2: | STE 900 | ||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719039001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016221043 | ||||||||
| FaxNumber: | 5016222033 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 WERNER ST. | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016221043 | ||||||||
| FaxNumber: | 5016222033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | J5942 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 554306972 | 01 | MEDICARE LINKED | OTHER | 100079170A | 05 | OK | MEDICAID | 115829701 | 05 | TX | MEDICAID | 190656201 | 05 | TX | MEDICAID | 103425001 | 05 | AK | MEDICAID |