1558585240 NPI number — EBG HEALTH CARE II, INC.

Table of content: (NPI 1558585240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558585240 NPI number — EBG HEALTH CARE II, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EBG HEALTH CARE II, 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:
Provider Other Organization Name Type Code:
6
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:
1558585240
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 E TRAFFICWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65802-3174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-869-5522
Provider Business Mailing Address Fax Number:
417-831-7729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 N PRAIRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63107-2302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-652-6111
Provider Business Practice Location Address Fax Number:
314-652-1575
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOURLEY
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
417-869-5522

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  031678 , 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)





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