Provider Demographics
NPI:1699731208
Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Entity type:Organization
Organization Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ECKELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-6026
Mailing Address - Street 1:12 E APPLEBY RD
Mailing Address - Street 2:CLINIC ADMINISTRATION
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3901
Mailing Address - Country:US
Mailing Address - Phone:479-463-1704
Mailing Address - Fax:479-463-7864
Practice Address - Street 1:12 E APPLEBY RD
Practice Address - Street 2:WASHINGTON REGIONAL SENIOR CLINIC
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3901
Practice Address - Country:US
Practice Address - Phone:479-463-4444
Practice Address - Fax:479-463-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-22
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158990002Medicaid
AR5F342Medicare ID - Type Unspecified