Provider Demographics
NPI:1881650497
Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Entity Type:Organization
Organization Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Other - Org Name:WASHINGTON REGIONAL SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR CLINIC ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:ROTHROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-1390
Mailing Address - Street 1:PO BOX 879
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-0879
Mailing Address - Country:US
Mailing Address - Phone:479-713-7115
Mailing Address - Fax:479-713-7186
Practice Address - Street 1:82 W SUNBRIDGE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-575-9000
Practice Address - Fax:479-251-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C569Medicare ID - Type Unspecified