Healthcare Provider Details

I. General information

NPI: 1184217077
Provider Name (Legal Business Name): MISSOURI DELTA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HOSPITALITY DR UNIT B
SIKESTON MO
63801
US

IV. Provider business mailing address

102 HOSPITALITY DR
SIKESTON MO
63801-9382
US

V. Phone/Fax

Practice location:
  • Phone: 573-838-2700
  • Fax: 573-838-2701
Mailing address:
  • Phone: 573-471-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MAURA ELIS RUSSELL
Title or Position: SECRETARY
Credential:
Phone: 573-472-7423