Provider Demographics
NPI:1033487194
Name:BOTHWELL REGIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:BOTHWELL REGIONAL HEALTH CENTER
Other - Org Name:BOTHWELL FAMILY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-827-9482
Mailing Address - Street 1:601 E 14TH ST
Mailing Address - Street 2:P O BOX 1706
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5972
Mailing Address - Country:US
Mailing Address - Phone:866-678-5627
Mailing Address - Fax:660-827-3742
Practice Address - Street 1:3700 W 10TH STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2540
Practice Address - Country:US
Practice Address - Phone:660-827-2500
Practice Address - Fax:660-827-2511
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOTHWELL REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-05
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid