Basic Information
Provider Information | |||||||||
NPI: | 1740311471 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BATES COUNTY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BCMH SURGICAL CARE CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 03/07/2007 | ||||||||
LastUpdateDate: | 05/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUSTLE | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | PHILLIP | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6602007000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BATES COUNTY MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 05/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2000165893 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 37710014 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | 540673605 | 05 | MO |   | MEDICAID |