Basic Information
| Provider Information | |||||||||
| NPI: | 1508239781 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOTHWELL REGIONAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOTHWELL PHYSICIANS GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 E 14TH ST | ||||||||
| Address2: | PO BOX 1706 | ||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653015972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608268833 | ||||||||
| FaxNumber: | 6608273742 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653012540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608272730 | ||||||||
| FaxNumber: | 6608272731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2015 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6608279482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOTHWELL REGIONAL HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.