Provider Demographics
NPI:1194846550
Name:NORTHWEST HEALTH SERVICES INC
Entity Type:Organization
Organization Name:NORTHWEST HEALTH SERVICES INC
Other - Org Name:SOUTH SIDE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-232-6818
Mailing Address - Street 1:5001 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64504-1170
Mailing Address - Country:US
Mailing Address - Phone:816-238-7788
Mailing Address - Fax:816-238-9285
Practice Address - Street 1:5001 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64504-1170
Practice Address - Country:US
Practice Address - Phone:816-238-7788
Practice Address - Fax:816-238-9285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509384202Medicaid
F290000AMedicare ID - Type UnspecifiedMEDICARE PART B GROUP #
DD8059Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP #
MO509384202Medicaid