Basic Information
Provider Information | |||||||||
NPI: | 1841312444 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HAMILTON MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 E CROSS STREET | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | MO | ||||||||
PostalCode: | 646448311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8165832151 | ||||||||
FaxNumber: | 8165832342 | ||||||||
Practice Location | |||||||||
Address1: | 101 E CROSS STREET | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | MO | ||||||||
PostalCode: | 64644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8165832713 | ||||||||
FaxNumber: | 8165832342 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2007 | ||||||||
LastUpdateDate: | 11/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNGER | ||||||||
AuthorizedOfficialFirstName: | MATT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8162326818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 501330427 | 05 | MO |   | MEDICAID |