Provider Demographics
NPI:1982733937
Name:WESTBROOK MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:WESTBROOK MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WESTBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-667-2923
Mailing Address - Street 1:107 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AR
Mailing Address - Zip Code:72949-2796
Mailing Address - Country:US
Mailing Address - Phone:479-667-2923
Mailing Address - Fax:479-667-2857
Practice Address - Street 1:107 N 9TH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AR
Practice Address - Zip Code:72949-2796
Practice Address - Country:US
Practice Address - Phone:479-667-2923
Practice Address - Fax:479-667-2857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127408002Medicaid
AR5B679Medicare ID - Type Unspecified