Basic Information
| Provider Information | |||||||||
| NPI: | 1023574365 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT FRANCIS MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | SAINT FRANCIS CLINIC POPLAR BLUFF NORTHWEST MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801143 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315583 | ||||||||
| FaxNumber: | 5733315079 | ||||||||
| Practice Location | |||||||||
| Address1: | 2210 BARRON RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737852005 | ||||||||
| FaxNumber: | 5737859444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2019 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | GILLILAND | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5733315583 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.