Basic Information
| Provider Information | |||||||||
| NPI: | 1043401284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOTHWELL REGIONAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOTHWELL SLEEP DISORDERS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1706 | ||||||||
| Address2: | 601 E 14TH STREET | ||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608268833 | ||||||||
| FaxNumber: | 6608273742 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 TOWER DR | ||||||||
| Address2: | SUTIE B | ||||||||
| City: | WARSAW | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6604380012 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 03/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6608279482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOTHWELL REGIONAL HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 509328902 | 05 | MO | MEDICAID |