Provider Demographics
NPI:1114924768
Name:SGOH ACQUISITION INC
Entity Type:Organization
Organization Name:SGOH ACQUISITION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-837-4000
Mailing Address - Street 1:1540 E EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4300
Mailing Address - Country:US
Mailing Address - Phone:417-823-2900
Mailing Address - Fax:417-886-2774
Practice Address - Street 1:1540 E EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4300
Practice Address - Country:US
Practice Address - Phone:417-823-2900
Practice Address - Fax:417-886-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4546261Q00000X
283Q00000X
MO454-8332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No283Q00000XHospitalsPsychiatric Hospital
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010564409Medicaid
AR121295105Medicaid
MO540564408Medicaid
MOCR0762OtherRR MEDICARE
MO6056770001Medicare NSC
MOMA1327Medicare PIN
MO010564409Medicaid
MO260207Medicare Oscar/Certification