Provider Demographics
NPI:1477718179
Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Entity Type:Organization
Organization Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Other - Org Name:WASHINGTON REGIONAL RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-7775
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0550
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7187
Practice Address - Street 1:3215 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4424
Practice Address - Country:US
Practice Address - Phone:479-968-8279
Practice Address - Fax:479-968-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155590002Medicaid
AR155590002Medicaid