Basic Information
| Provider Information | |||||||||
| NPI: | 1952557399 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARROLL COUNTY HOSPITAL PHTYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646331948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605421695 | ||||||||
| FaxNumber: | 6605420363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1502 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646331948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605421695 | ||||||||
| FaxNumber: | 6605420363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | IRELAND | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6605421695 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARROLL COUNTY MEMORIAL HOSPITAL | ||||||||
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| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 21047 | MO | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 540157906 | 05 | MO | MEDICAID |