Basic Information
| Provider Information | |||||||||
| NPI: | 1114901527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAYNE MEDICAL CENTER, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 4 BOX 4515 | ||||||||
| Address2: | |||||||||
| City: | PIEDMONT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639579417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732234233 | ||||||||
| FaxNumber: | 5732232136 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 4 BOX 4515 | ||||||||
| Address2: | |||||||||
| City: | PIEDMONT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639579417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732234233 | ||||||||
| FaxNumber: | 5732232136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | GAYLE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5732234233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 595929902 | 01 | MO | MEDICAID RURAL HEALTH | OTHER | 263933 | 01 | MO | MEDICARE RURAL HEALTH | OTHER | 595929901 | 05 | MO | MEDICAID |