MEDICARE: WASHINGTON REGIONAL MEDICAL SYSTEM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1275839011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON REGIONAL MEDICAL SYSTEM

Provider Business Mailing Address
First Line	:	12 E APPLEBY RD
Second Line	:	CLINIC ADMINISTRATION
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-3901
Country	:	US
Telephone Number	:	479-463-1704
Fax Number	:	479-463-7864

Provider Business Practice Location Address
First Line	:	199 E MAIN ST
Second Line	:
City	:	FARMINGTON
State	:	AR
Zip	:	72730-3077
Country	:	US
Telephone Number	:	479-267-1001
Fax Number	:	479-267-1026

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT AND CFO
Name	:	DANIEL R ECKELS
Credential	:
Telephone Number	:	479-463-6026

Provider Enumeration Date	:	01/26/2011
Last Update Date	:	01/26/2011

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