Basic Information
Provider Information | |||||||||
NPI: | 1760884894 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAMERON REGIONAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CAMERON OBSTETRICS AND GYNECOLOGY CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 E EVERGREEN ST | ||||||||
Address2: |   | ||||||||
City: | CAMERON | ||||||||
State: | MO | ||||||||
PostalCode: | 644292400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8166322101 | ||||||||
FaxNumber: | 8166493383 | ||||||||
Practice Location | |||||||||
Address1: | 1600 E EVERGREEN ST | ||||||||
Address2: | MP II STE A | ||||||||
City: | CAMERON | ||||||||
State: | MO | ||||||||
PostalCode: | 644292400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8166490500 | ||||||||
FaxNumber: | 8166490049 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2014 | ||||||||
LastUpdateDate: | 09/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ABRUTZ | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8166493203 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 473-12 | MO | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 1811905375 | 05 | MO |   | MEDICAID |