Basic Information
| Provider Information | |||||||||
| NPI: | 1104947126 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAVANNAH MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 803 HIGHWAY 71 WEST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644851151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163243121 | ||||||||
| FaxNumber: | 8163243122 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 HIGHWAY 71 WEST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163243121 | ||||||||
| FaxNumber: | 8163243122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | YOUNGER | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8162326818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 500739511 | 05 | MO | MEDICAID |