=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326324690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILHELMINA EMERGENCY PHYSICIANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2011
-----------------------------------------------------
Last Update Date | 12/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 MORROW ST N
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-2516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-394-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13737 NOEL RD STE 1600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75240-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-401-2386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC. VICE PRESIDENT
-----------------------------------------------------
Name | MR. ROSS RONAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-401-2386
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------