Provider Demographics
NPI:1851315501
Name:MIDSTATE MEDICAL SERVICES PA
Entity type:Organization
Organization Name:MIDSTATE MEDICAL SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GLYN
Authorized Official - Last Name:WAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-525-5840
Mailing Address - Street 1:3810 CENTRAL AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6921
Mailing Address - Country:US
Mailing Address - Phone:501-525-5840
Mailing Address - Fax:501-525-1762
Practice Address - Street 1:3810 CENTRAL AVE
Practice Address - Street 2:SUITE H
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6921
Practice Address - Country:US
Practice Address - Phone:501-525-5840
Practice Address - Fax:501-525-1762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC1263207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B942Medicare ID - Type Unspecified