Healthcare Provider Details

I. General information

NPI: 1184174567
Provider Name (Legal Business Name): MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 COLLEGE ST
BOURBON MO
65441-8308
US

IV. Provider business mailing address

751 SAPPINGTON BRIDGE RD ADMINISTRATION
SULLIVAN MO
63080-2354
US

V. Phone/Fax

Practice location:
  • Phone: 573-732-5004
  • Fax:
Mailing address:
  • Phone: 573-468-4186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TONY L SCHWARM
Title or Position: PRESIDENT
Credential:
Phone: 573-468-4186