Basic Information
| Provider Information | |||||||||
| NPI: | 1962591958 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSOURI BAPTIST HOSPITAL OF SULLIVAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERSIDE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149967644 | ||||||||
| FaxNumber: | 3149967658 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PROGRESS PKWY | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630802359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734863555 | ||||||||
| FaxNumber: | 3149963610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | NORONHA | ||||||||
| AuthorizedOfficialFirstName: | AUGUSTO | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 3149965118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 355-24 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.