Provider Demographics
NPI:1154324796
Name:BATESVILLE FAMILY PRACTICE CLINIC PA
Entity Type:Organization
Organization Name:BATESVILLE FAMILY PRACTICE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDRIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-793-1126
Mailing Address - Street 1:1215 SIDNEY ST
Mailing Address - Street 2:STE 300
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7201
Mailing Address - Country:US
Mailing Address - Phone:870-793-1126
Mailing Address - Fax:870-793-1180
Practice Address - Street 1:1215 SIDNEY ST
Practice Address - Street 2:STE 300
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7201
Practice Address - Country:US
Practice Address - Phone:870-793-1126
Practice Address - Fax:870-793-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC1957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C281OtherBLUE CROSS BLUE SHIELD
AR5C281OtherBLUE CROSS BLUE SHIELD