MEDICARE: WYNNE MEDICAL CLINIC PA

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548376148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYNNE MEDICAL CLINIC PA

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:
City	:	WYNNE
State	:	AR
Zip	:	72396-0158
Country	:	US
Telephone Number	:	870-238-2321
Fax Number	:	870-238-0114

Provider Business Practice Location Address
First Line	:	710 FALLS BLVD S
Second Line	:
City	:	WYNNE
State	:	AR
Zip	:	72396-3514
Country	:	US
Telephone Number	:	870-238-2321
Fax Number	:	870-238-0114

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. SHELIA BURROW
Credential	:
Telephone Number	:	870-238-2321

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	09/24/2013

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Directions to “WYNNE MEDICAL CLINIC PA ” Practice Location

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