Provider Demographics
NPI:1073748786
Name:JOHN FITZGIBBON MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:JOHN FITZGIBBON MEMORIAL HOSPITAL INC
Other - Org Name:FITZGIBBON WOUND CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-886-7231
Mailing Address - Street 1:2305 SOUTH 65 HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3702
Mailing Address - Country:US
Mailing Address - Phone:660-886-7431
Mailing Address - Fax:660-886-9001
Practice Address - Street 1:2305 SOUTH 65 HIGHWAY
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3702
Practice Address - Country:US
Practice Address - Phone:660-886-7431
Practice Address - Fax:660-886-9001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN FITZGIBBON MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-26
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109128163WW0000X
MO27-57163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073748786Medicaid
E290000Medicare Oscar/Certification