Provider Demographics
NPI:1477523348
Name:WHITE RIVER HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:WHITE RIVER HEALTH SYSTEM, INC.
Other - Org Name:MELBOURNE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE COORDIN
Authorized Official - Prefix:
Authorized Official - First Name:WOODROW
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTLEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-262-1160
Mailing Address - Street 1:P.O. BOX 37
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:AR
Mailing Address - Zip Code:72556-0037
Mailing Address - Country:US
Mailing Address - Phone:870-368-4344
Mailing Address - Fax:870-368-3051
Practice Address - Street 1:1526 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556
Practice Address - Country:US
Practice Address - Phone:870-368-4344
Practice Address - Fax:870-368-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56876OtherBCBS
AR124189729Medicaid
AR04-3997Medicare PIN
AR5G843Medicare PIN