Provider Demographics
NPI:1366408973
Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Entity type:Organization
Organization Name:WASHINGTON REGIONAL MEDICAL SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-6026
Mailing Address - Street 1:12 E APPLEBY
Mailing Address - Street 2:CLINIC ADMINISTRATION
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-463-1704
Mailing Address - Fax:479-463-7864
Practice Address - Street 1:3215 N NORTHHILLS BLVD
Practice Address - Street 2:WASHINGTON REGIONAL PSYCHIATRIC CLINIC
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4424
Practice Address - Country:US
Practice Address - Phone:479-463-2004
Practice Address - Fax:479-463-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-22
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148784002Medicaid
AR5C734Medicare ID - Type Unspecified