Provider Demographics
NPI:1275584575
Name:TWIN LAKES MEDICAL SPECIALISTS, PA
Entity Type:Organization
Organization Name:TWIN LAKES MEDICAL SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-425-4402
Mailing Address - Street 1:628 HOSPITAL DRIVE GROUND FLOOR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2953
Mailing Address - Country:US
Mailing Address - Phone:870-425-4402
Mailing Address - Fax:870-424-3089
Practice Address - Street 1:628 HOSPITAL DRIVE GROUND FLOOR
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2953
Practice Address - Country:US
Practice Address - Phone:870-425-4402
Practice Address - Fax:870-425-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121749002Medicaid
AR5B019Medicare PIN