Provider Demographics
NPI:1811068646
Name:GREAT RIVER MEDICAL CENTER
Entity type:Organization
Organization Name:GREAT RIVER MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-838-7462
Mailing Address - Street 1:PO BOX 167
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72316-0167
Mailing Address - Country:US
Mailing Address - Phone:870-838-7213
Mailing Address - Fax:870-838-7100
Practice Address - Street 1:1520 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1448
Practice Address - Country:US
Practice Address - Phone:870-838-7213
Practice Address - Fax:838-870-7100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIS OF ARKANSAS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4258282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F636Medicare ID - Type UnspecifiedM'CARE PRO FEE