1679571590 NPI number — THEODOSIA MEDICAL CENTER

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 1679571590 NPI number — THEODOSIA MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THEODOSIA 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:
Provider Other Organization Name Type Code:
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:
1679571590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 IOWA COLONY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLISTER
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65672-5270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-239-0079
Provider Business Mailing Address Fax Number:
417-239-1228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US HIGHWAY 160
Provider Second Line Business Practice Location Address:
#1
Provider Business Practice Location Address City Name:
THEODOSIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-273-4449
Provider Business Practice Location Address Fax Number:
417-273-4489
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
MARIAN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
417-273-4449

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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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