Basic Information
| Provider Information | |||||||||
| NPI: | 1528348786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRHC | ||||||||
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| OtherOrganizationName: | MISSOURI HEART-SEDALIA | ||||||||
| 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: | 8666785627 | ||||||||
| FaxNumber: | 6608273742 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 W 10TH STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653012540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608271771 | ||||||||
| FaxNumber: | 6608271488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2011 | ||||||||
| LastUpdateDate: | 12/02/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6608279482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOTHWELL REGIONAL HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 45896011 | 01 | MO | BLUE CROSS | OTHER | PENDING | 05 | MO | MEDICAID |