Basic Information
| Provider Information | |||||||||
| NPI: | 1275886947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOTHWELL INTERNAL MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 E 14TH STREET | ||||||||
| Address2: | PO BOX 1706 | ||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6606680851 | ||||||||
| FaxNumber: | 6608273742 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 W 10TH ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653012540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608272500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2012 | ||||||||
| LastUpdateDate: | 02/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6608279482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOTHWELL REGIONAL HEALTH CENTER | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | MP | MEDICAID |