Provider Demographics
NPI:1184658387
Name:STE GENEVIEVE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:STE GENEVIEVE COUNTY MEMORIAL HOSPITAL
Other - Org Name:BLOOMSDALE FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-883-7703
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-0366
Mailing Address - Country:US
Mailing Address - Phone:573-883-4477
Mailing Address - Fax:
Practice Address - Street 1:255 BODERMAN
Practice Address - Street 2:
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627-9099
Practice Address - Country:US
Practice Address - Phone:573-483-9492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STE GENEVIEVE COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-11
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCC8331OtherRAILROAD MEDICARE
MO268647Medicare Oscar/Certification
MO000013535Medicare PIN