Healthcare Provider Details

I. General information

NPI: 1821151622
Provider Name (Legal Business Name): CROSS TRAILS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 HWY 51 NORTH
MARBLE HILL MO
63764
US

IV. Provider business mailing address

PO BOX 349
MARBLE HILL MO
63764-0349
US

V. Phone/Fax

Practice location:
  • Phone: 573-238-2725
  • Fax: 573-238-3795
Mailing address:
  • Phone: 573-238-2725
  • Fax: 573-238-9795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICKI A SMITH
Title or Position: CEO
Credential:
Phone: 573-332-0808