Provider Demographics
NPI:1003862251
Name:WHARTON CLINIC, PA
Entity Type:Organization
Organization Name:WHARTON CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WHARTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-226-6786
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:AR
Mailing Address - Zip Code:71671-0850
Mailing Address - Country:US
Mailing Address - Phone:870-226-6786
Mailing Address - Fax:870-226-5638
Practice Address - Street 1:1012 E CHURCH ST
Practice Address - Street 2:SUITE C
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-3509
Practice Address - Country:US
Practice Address - Phone:870-226-6786
Practice Address - Fax:870-226-5638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1279200000OtherQUALCHOICE
AR=========OtherAETNA
AR5C694Medicare ID - Type Unspecified