Provider Demographics
NPI:1073636551
Name:WADE FALWELL, M.D.,P.A.
Entity Type:Organization
Organization Name:WADE FALWELL, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:FALWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-523-3053
Mailing Address - Street 1:2000 MCLAIN ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-3661
Mailing Address - Country:US
Mailing Address - Phone:870-523-3053
Mailing Address - Fax:870-523-3637
Practice Address - Street 1:2000 MCLAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3661
Practice Address - Country:US
Practice Address - Phone:870-523-3053
Practice Address - Fax:870-523-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207Q00000X261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117464002Medicaid
AR114224001Medicaid
AR1458600000OtherQUALCHOICE
AR080017871OtherRAILROAD MEDICARE
AR50313OtherARKANSAS BLUECROSS
AR114224001Medicaid
AR117464002Medicaid
AR114224001Medicaid