Basic Information
| Provider Information | |||||||||
| NPI: | 1033478557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMERON REGIONAL MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BETHANY HEALTH SERVICES CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 E EVERGREEN ST | ||||||||
| Address2: | |||||||||
| City: | CAMERON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644292400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166322101 | ||||||||
| FaxNumber: | 8166493383 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 N 25TH ST | ||||||||
| Address2: | |||||||||
| City: | BETHANY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644241501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6604257333 | ||||||||
| FaxNumber: | 6604257346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2012 | ||||||||
| LastUpdateDate: | 12/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | ABRUTZ | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8166493203 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 473-10 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.