Healthcare Provider Details

I. General information

NPI: 1528014156
Provider Name (Legal Business Name): SSM REGIONAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 E NORTH ST
ELDON MO
65026-2602
US

IV. Provider business mailing address

PO BOX 1027
JEFFERSON CITY MO
65102-1027
US

V. Phone/Fax

Practice location:
  • Phone: 573-392-3767
  • Fax: 573-392-1976
Mailing address:
  • Phone: 573-761-7246
  • Fax: 573-761-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRENT VAN CONIA
Title or Position: PRESIDENT
Credential:
Phone: 573-761-7000