Provider Demographics
NPI:1093834574
Name:ROLLIN WYCOFF MD
Entity Type:Organization
Organization Name:ROLLIN WYCOFF MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYCOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-807-1294
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71711-0216
Mailing Address - Country:US
Mailing Address - Phone:870-807-1294
Mailing Address - Fax:866-625-0076
Practice Address - Street 1:2285 MAUL RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-2511
Practice Address - Country:US
Practice Address - Phone:870-807-1294
Practice Address - Fax:866-625-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158635002Medicaid