Provider Demographics
NPI:1710233010
Name:WHITE RIVER HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:WHITE RIVER HEALTH SYSTEM, INC
Other - Org Name:STONE COUNTY ANESTHESIA GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BEBOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-262-6091
Mailing Address - Street 1:2106 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560-6439
Mailing Address - Country:US
Mailing Address - Phone:870-269-4361
Mailing Address - Fax:
Practice Address - Street 1:2106 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560-6439
Practice Address - Country:US
Practice Address - Phone:870-269-4361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STONE COUNTY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112094002Medicaid