Basic Information
| Provider Information | |||||||||
| NPI: | 1780778449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LESTER E COX MEDICAL CENTERS | ||||||||
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| OtherOrganizationName: | COXHEALTH CENTER MT. VERNON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 S NATIONAL AVE | ||||||||
| Address2: | #540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172695712 | ||||||||
| FaxNumber: | 4172694869 | ||||||||
| Practice Location | |||||||||
| Address1: | 10763 HIGHWAY 39 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657127823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172692460 | ||||||||
| FaxNumber: | 4172692462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4174662875 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 116760 | 01 | BLUE CROSS OF MO | OTHER | 508603909 | 05 | MO | MEDICAID | 598603900 | 05 | MO | MEDICAID |