Basic Information
| Provider Information | |||||||||
| NPI: | 1598703381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BATES COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BATES COUNTY MEMORIAL HOSPITAL SWING BED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 615 W NURSERY ST | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647301840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602007000 | ||||||||
| FaxNumber: | 6602007015 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 W NURSERY ST | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647301840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602007000 | ||||||||
| FaxNumber: | 6602007015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUSTLE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | PHILLIP | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6602007000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 205 45 | MO | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 90012015 | 01 | MO | BLUE CROSS | OTHER |