Basic Information
| Provider Information | |||||||||
| NPI: | 1053499707 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SKAGGS COMMUNITY HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COXHEALTH CENTER KIMBERLING CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4046 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172697241 | ||||||||
| FaxNumber: | 4172697567 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 KIMBERLING BLVD | ||||||||
| Address2: | |||||||||
| City: | KIMBERLING CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177392520 | ||||||||
| FaxNumber: | 4173357544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | MAHONEY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4173357270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5248 | MO | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 507219301 | 05 | MO | MEDICAID | 598594802 | 05 | MO | MEDICAID | C43561 | 01 | RAILROAD MEDICARE | OTHER |