Provider Demographics
NPI:1710003579
Name:STUTTGART REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:STUTTGART REGIONAL MEDICAL CENTER
Other - Org Name:BRINKLEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-674-6783
Mailing Address - Street 1:110 N NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:BRINKLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72021-2722
Mailing Address - Country:US
Mailing Address - Phone:870-734-4405
Mailing Address - Fax:870-734-3438
Practice Address - Street 1:110 N NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:BRINKLEY
Practice Address - State:AR
Practice Address - Zip Code:72021-2722
Practice Address - Country:US
Practice Address - Phone:870-734-4405
Practice Address - Fax:870-734-3438
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STUTTGART REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-22
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B746Medicare PIN