Healthcare Provider Details

I. General information

NPI: 1396827408
Provider Name (Legal Business Name): MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 OZARK STREET SUITE B
CUBA MO
65453-1664
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR SUITE 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 573-885-6600
  • Fax: 314-996-3610
Mailing address:
  • Phone: 314-996-7644
  • Fax: 314-996-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number355-24
License Number StateMO

VIII. Authorized Official

Name: MR. TONY L SCHWARM
Title or Position: PRESIDENT
Credential:
Phone: 573-468-1343