Provider Demographics
NPI:1053452623
Name:NORTHWEST MEDICAL CENTER ASSOCIATION, INC
Entity Type:Organization
Organization Name:NORTHWEST MEDICAL CENTER ASSOCIATION, INC
Other - Org Name:NMC GRANT CITY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOOLITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:660-726-3941
Mailing Address - Street 1:16 W. 4TH ST.
Mailing Address - Street 2:PO BOX 187
Mailing Address - City:GRANT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64456
Mailing Address - Country:US
Mailing Address - Phone:660-564-3322
Mailing Address - Fax:660-564-3324
Practice Address - Street 1:16 W. 4TH ST.
Practice Address - Street 2:
Practice Address - City:GRANT CITY
Practice Address - State:MO
Practice Address - Zip Code:64456
Practice Address - Country:US
Practice Address - Phone:660-564-3322
Practice Address - Fax:660-564-3324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST MEDICAL CENTER ASSOCIATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2019-06-06
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
MO505708305Medicaid
MOL280000Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
MOL280000Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
MO1952340317OtherALLISON THORN NPI
MO505708305Medicaid