Provider Demographics
NPI:1477004109
Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Entity Type:Organization
Organization Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Other - Org Name:COLON AND RECTAL CLINIC - WASHINGTON REGIONAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-1000
Mailing Address - Street 1:203 S BLOOMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-9490
Mailing Address - Country:US
Mailing Address - Phone:479-770-0728
Mailing Address - Fax:479-770-0712
Practice Address - Street 1:203 S BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9490
Practice Address - Country:US
Practice Address - Phone:479-770-0728
Practice Address - Fax:479-770-0712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty