Provider Demographics
NPI:1215118492
Name:WHITE RIVER HEALTH SYSTEM,INC.
Entity type:Organization
Organization Name:WHITE RIVER HEALTH SYSTEM,INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEBOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-262-6091
Mailing Address - Street 1:197 HOSPITAL DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72529-7314
Mailing Address - Country:US
Mailing Address - Phone:870-257-6061
Mailing Address - Fax:870-257-7667
Practice Address - Street 1:197 HOSPITAL DR
Practice Address - Street 2:SUITE D
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529-7314
Practice Address - Country:US
Practice Address - Phone:870-257-6070
Practice Address - Fax:870-257-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR15386OtherCERTIFICATION
ARAR4463OtherSTATE LICENSE
AR11076OtherMEDICARE PTAN
AR175016128Medicaid