Healthcare Provider Details

I. General information

NPI: 1104097500
Provider Name (Legal Business Name): WASHINGTON REGIONAL MEDICAL SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3336 N FUTRALL DR
FAYETTEVILLE AR
72703-4057
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 479-463-3000
  • Fax: 479-469-3050
Mailing address:
  • Phone: 479-463-1704
  • Fax: 479-463-7864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL ECKELS
Title or Position: SENIOR VICE PRESIDENT/CFO
Credential:
Phone: 479-463-1704