Healthcare Provider Details

I. General information

NPI: 1336350214
Provider Name (Legal Business Name): SSM AUDRAIN HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 S CLARK ST SUITE A
MEXICO MO
65265-4104
US

IV. Provider business mailing address

1001 SOUTHWEST BLVD STE A
JEFFERSON CITY MO
65109-2501
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-7366
  • Fax: 573-581-7422
Mailing address:
  • Phone: 573-681-3000
  • Fax: 573-761-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JAMES T STRATTON
Title or Position: REGIONAL CFO
Credential:
Phone: 573-681-3129