Basic Information
Provider Information | |||||||||
NPI: | 1467424788 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WASHINGTON COUNTY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AUSTIN PLAZA PRIMARY CARE CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 108 FRIZZELL STREET | ||||||||
Address2: |   | ||||||||
City: | POTOSI | ||||||||
State: | MO | ||||||||
PostalCode: | 63664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5734388500 | ||||||||
FaxNumber: | 5734388787 | ||||||||
Practice Location | |||||||||
Address1: | 108 FRIZZELL STREET | ||||||||
Address2: |   | ||||||||
City: | POTOSI | ||||||||
State: | MO | ||||||||
PostalCode: | 63664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5734388500 | ||||||||
FaxNumber: | 5734388787 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2006 | ||||||||
LastUpdateDate: | 08/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRATT | ||||||||
AuthorizedOfficialFirstName: | DEBRA | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5734385451 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 598658003 | 05 | MO |   | MEDICAID |