NPIMap

Organization Active NPI

Washington Regional Medical System

Doing business as Washington Regional Family Clinic Fayetteville

  • Family Medicine Physician
  • Fayetteville, AR
National Provider Identifier
1114971819
Registry record updated Mar 25, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
WASHINGTON REGIONAL MEDICAL SYSTEM
Doing business as
Washington Regional Family Clinic Fayetteville
Practice address
3053 N College Avenue
Fayetteville, AR 72703
Phone
(479) 463-2000
Fax
(479) 442-4518
NPI assigned
May 19, 2006
Last updated
Mar 25, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 25, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mary Jo Rothrock
Title
Director Clinic Administration
Phone
(479) 463-1390

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

3053 N College Avenue
Fayetteville, AR 72703

Mailing address

PO Box 879
Fayetteville, AR 72702-0879
Phone (479) 713-7115

Other names 1

  • Washington Regional Family Clinic Fayetteville Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040210001051 AR Part B Supplier - Clinic/Group Practice 8820995434 Receives reassigned benefits from 17 practitioners
Practice locations: Fayetteville, AR

Other NPIs with the same Medicare PAC ID 12

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

3 E Appleby Rd
Ste 302
Fayetteville, AR 72703
Phone (479) 404-1400

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Encompass Health Rehabilitation Hospital, a Partner of Washington RegiFayetteville, AR, CCN 043032 Hospital 5% Or Greater Indirect Ownership Interest (50%) Dec 31, 2007

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1206403200000",
    "number": "1114971819",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 879",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727020879",
            "telephone_number": "479-713-7115",
            "fax_number": "479-713-7186"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3053 N COLLEGE AVENUE",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "72703",
            "telephone_number": "479-463-2000",
            "fax_number": "479-442-4518"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WASHINGTON REGIONAL MEDICAL SYSTEM",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-19",
        "last_updated": "2008-03-25",
        "status": "A",
        "authorized_official_last_name": "ROTHROCK",
        "authorized_official_first_name": "MARY",
        "authorized_official_middle_name": "JO",
        "authorized_official_title_or_position": "DIRECTOR CLINIC ADMINISTRATION",
        "authorized_official_telephone_number": "479-463-1390"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Washington Regional Family Clinic Fayetteville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fayetteville, AR

Sources for this page

Verify at the official NPI Registry.