Provider Demographics
NPI:1801042924
Name:PEDIATRIC ASSOCIATES OF W MPHS
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF W MPHS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-732-1191
Mailing Address - Street 1:108 W TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:132 BLOCK ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1956
Practice Address - Country:US
Practice Address - Phone:870-739-1190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty