Healthcare Provider Details

I. General information

NPI: 1790953909
Provider Name (Legal Business Name): MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 N COMMERCIAL AVE
SAINT CLAIR MO
63077-1118
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 636-629-7467
  • Fax: 636-629-7464
Mailing address:
  • Phone: 314-996-7644
  • Fax: 314-996-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND P. DAVIDSON II
Title or Position: PRESIDENT
Credential: MD
Phone: 314-286-2025