=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740480169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STUTTGART MEDICAL CLINIC LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2007
-----------------------------------------------------
Last Update Date | 03/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1609 N MEDICAL DR
-----------------------------------------------------
City | STUTTGART
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72160-3274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-673-7211
-----------------------------------------------------
Fax | 870-672-6823
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1901
-----------------------------------------------------
City | STUTTGART
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72160-1901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-673-3511
-----------------------------------------------------
Fax | 870-672-6823
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | LURA WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-674-6783
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------