Basic Information
| Provider Information | |||||||||
| NPI: | 1326084948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LESTER E COX MEDICAL CENTERS | ||||||||
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| OtherOrganizationName: | OZARKS DIALYSIS SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 N JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658021917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172693000 | ||||||||
| FaxNumber: | 4172693104 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 E US HIGHWAY 60 | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MONETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657082668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173541111 | ||||||||
| FaxNumber: | 4172362666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 05/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCWAY | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE-PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4172698811 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 120907 | 01 | BCBS MO | OTHER | 502989353 | 05 | MO | MEDICAID |