Provider Demographics
NPI:1861518698
Name:STUTTGART MEDICAL CLINIC, LTD
Entity type:Organization
Organization Name:STUTTGART MEDICAL CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-674-6783
Mailing Address - Street 1:1609 N MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:STUTTGART
Mailing Address - State:AR
Mailing Address - Zip Code:72160-3274
Mailing Address - Country:US
Mailing Address - Phone:870-673-7211
Mailing Address - Fax:870-672-6823
Practice Address - Street 1:1609 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:STUTTGART
Practice Address - State:AR
Practice Address - Zip Code:72160-3274
Practice Address - Country:US
Practice Address - Phone:870-673-7211
Practice Address - Fax:870-672-6823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100907002Medicaid
AR100907002Medicaid