Provider Demographics
NPI:1598715302
Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Entity Type:Organization
Organization Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Other - Org Name:WASHINGTON REGIONAL DIAGNOSTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ECKELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-6026
Mailing Address - Street 1:12 E APPLEBY RD
Mailing Address - Street 2:CLINIC ADMINISTRATION
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3901
Mailing Address - Country:US
Mailing Address - Phone:479-463-1704
Mailing Address - Fax:479-463-7864
Practice Address - Street 1:3000 NW A ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3985
Practice Address - Country:US
Practice Address - Phone:479-268-3050
Practice Address - Fax:479-268-3061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135445004Medicaid
AR57985Medicare ID - Type Unspecified