Healthcare Provider Details

I. General information

NPI: 1093289431
Provider Name (Legal Business Name): MOSAIC MEDICAL CENTER - MARYVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E PRICE AVE STE A
SAVANNAH MO
64485-2482
US

IV. Provider business mailing address

301 E PRICE AVE STE A
SAVANNAH MO
64485-2482
US

V. Phone/Fax

Practice location:
  • Phone: 816-432-0006
  • Fax: 816-432-0008
Mailing address:
  • Phone: 816-432-0006
  • Fax: 816-432-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DWIGHT R CARVELL
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 816-273-0473