MEDICARE: DEXTER HOSPITAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician		MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC5318	OTHER	MO	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1326108226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEXTER HOSPITAL LLC

Provider Business Mailing Address
First Line	:	PO BOX 368
Second Line	:
City	:	DEXTER
State	:	MO
Zip	:	63841
Country	:	US
Telephone Number	:	573-624-3165
Fax Number	:	573-624-3157

Provider Business Practice Location Address
First Line	:	1003 HIGHWAY 25 NORTH
Second Line	:
City	:	BLOOMFIELD
State	:	MO
Zip	:	63825
Country	:	US
Telephone Number	:	573-568-3686
Fax Number	:

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	SUE ANN WILLIAMS
Credential	:
Telephone Number	:	573-624-1640

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	04/09/2008

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Directions to “DEXTER HOSPITAL LLC ” Practice Location

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