Provider Demographics
NPI:1548376148
Name:WYNNE MEDICAL CLINIC PA
Entity type:Organization
Organization Name:WYNNE MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-238-2321
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-0158
Mailing Address - Country:US
Mailing Address - Phone:870-238-2321
Mailing Address - Fax:870-238-0114
Practice Address - Street 1:710 FALLS BLVD S
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3514
Practice Address - Country:US
Practice Address - Phone:870-238-2321
Practice Address - Fax:870-238-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102040002Medicaid
AR102040002Medicaid