1376679423 NPI number — OZARKS MEDICAL CENTER

Table of content: (NPI 1376679423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376679423 NPI number — OZARKS MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OZARKS MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OZARKS HEALTHCARE MOUNTAIN GROVE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376679423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PLAINS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65775-1100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-256-9111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 EAST 19TH STREET
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MOUNTAIN GROVE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-926-6563
Provider Business Practice Location Address Fax Number:
417-926-5820
Provider Enumeration Date:
02/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
417-256-9111

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  17447 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 599301009 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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