1750457149 NPI number — NORTHWEST MEDICAL CENTER ASSOCIATION, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750457149 NPI number — NORTHWEST MEDICAL CENTER ASSOCIATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST MEDICAL CENTER ASSOCIATION, INC
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:
MOSAIC FAMILY CARE STANBERRY
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:
1750457149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
705 N COLLEGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64402-1433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-726-3941
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STANBERRY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64489-1358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-783-2092
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOOLITTLE
Authorized Official First Name:
JON
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
660-726-3941

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 590158309 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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