Basic Information
| Provider Information | |||||||||
| NPI: | 1437175320 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN FITZGIBBON MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARSHALL WOMENS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2305 SOUTH 65 HIGHWAY, BUILDING A | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653403702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608866677 | ||||||||
| FaxNumber: | 6608313346 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 SOUTH 65 HIGHWAY, BUILDING A | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653403702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608866677 | ||||||||
| FaxNumber: | 6608313346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAUG | ||||||||
| AuthorizedOfficialFirstName: | DARIN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6608867800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JOHN FITZGIBBON MEMORIAL HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1437175320 | 05 | MO | MEDICAID | 598987600 | 01 | MO | MEDICAID - RHC | OTHER | 268577 | 01 | MO | MEDICARE - RHC | OTHER |