MEDICARE: MISSOURI BAPTIST HOSPITAL OF SULLIVAN

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	207V00000X	Obstetrics & Gynecology Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1790953909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI BAPTIST HOSPITAL OF SULLIVAN

Provider Business Mailing Address
First Line	:	670 MASON RIDGE CENTER DR
Second Line	:	STE. 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8573
Country	:	US
Telephone Number	:	314-996-7644
Fax Number	:	314-996-7658

Provider Business Practice Location Address
First Line	:	875 N COMMERCIAL AVE
Second Line	:
City	:	SAINT CLAIR
State	:	MO
Zip	:	63077-1118
Country	:	US
Telephone Number	:	636-629-7467
Fax Number	:	636-629-7464

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAYMOND P. DAVIDSON II
Credential	:	MD
Telephone Number	:	314-286-2025

Provider Enumeration Date	:	02/11/2008
Last Update Date	:	02/11/2008

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Directions to “MISSOURI BAPTIST HOSPITAL OF SULLIVAN ” Practice Location

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