Basic Information
| Provider Information | |||||||||
| NPI: | 1326131475 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSOURI BAPTIST HOSPITAL OF SULLIVAN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BOURBON CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149967644 | ||||||||
| FaxNumber: | 3149967658 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | BOURBON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654418308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737325140 | ||||||||
| FaxNumber: | 3149963610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHWARM | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5734684186 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 355-24 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | CE7443 | 01 | MO | MEDICARE RAILROAD | OTHER | CG2664 | 01 | MO | MEDICARE RAILROAD | OTHER |