Provider Demographics
NPI:1760432629
Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Entity Type:Organization
Organization Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Other - Org Name:HERHEALTH BY WASHINGTON REGIONAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, SYSTEMS CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-1390
Mailing Address - Street 1:12 E APPLEBY RD
Mailing Address - Street 2:CLINICS 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 1:3215 N NORTH HILLS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-463-5500
Practice Address - Fax:479-463-5542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111898002Medicaid
AR57603Medicare ID - Type Unspecified