Healthcare Provider Details

I. General information

NPI: 1760432629
Provider Name (Legal Business Name): WASHINGTON REGIONAL MEDICAL SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 N NORTH HILLS BLVD SUITE B
FAYETTEVILLE AR
72703
US

IV. Provider business mailing address

12 E APPLEBY RD CLINICS ADMINISTRATION
FAYETTEVILLE AR
72703-3901
US

V. Phone/Fax

Practice location:
  • Phone: 479-463-5500
  • Fax: 479-463-5542
Mailing address:
  • Phone: 479-463-1704
  • Fax: 479-463-7864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: LARRY WILEY
Title or Position: EXECUTIVE DIRECTOR, SYSTEMS CLINICS
Credential:
Phone: 479-463-1390