Basic Information
| Provider Information | |||||||||
| NPI: | 1497784987 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FARMINGTON MISSOURI HOSPITAL COMPANY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MINERAL AREA ER ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1212 WEBER RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636403325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737564581 | ||||||||
| FaxNumber: | 5737565834 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 WEBER RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636403325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737564581 | ||||||||
| FaxNumber: | 5737565834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 6154657626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FARMINGTON MISSOURI HOSPITAL COMPANY, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.