Provider Demographics
NPI:1043424708
Name:CITIZENS MEMORIAL HEALTHCARE
Entity Type:Organization
Organization Name:CITIZENS MEMORIAL HEALTHCARE
Other - Org Name:HERMITAGE FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BABB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-326-6000
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:MO
Mailing Address - Zip Code:65668-0125
Mailing Address - Country:US
Mailing Address - Phone:417-745-2121
Mailing Address - Fax:
Practice Address - Street 1:HWY 254 & DALLAS
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:MO
Practice Address - Zip Code:65668-0125
Practice Address - Country:US
Practice Address - Phone:417-745-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITIZENS MEMORIAL HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-10
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263978Medicare Oscar/Certification