Provider Demographics
NPI:1023015468
Name:SOUTHERN CROSS MEDICAL SERVICES INC
Entity Type:Organization
Organization Name:SOUTHERN CROSS MEDICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-339-7185
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0326
Mailing Address - Country:US
Mailing Address - Phone:573-339-7185
Mailing Address - Fax:573-339-1079
Practice Address - Street 1:319 S SILVER SPRINGS RD
Practice Address - Street 2:STE A
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-339-7185
Practice Address - Fax:573-339-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000060205207L00000X
367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1771OtherBLUE CROSS
MO506882307Medicaid
000060205Medicare ID - Type Unspecified