Provider Demographics
NPI:1225191752
Name:CROSS TRAILS MEDICAL CENTER
Entity Type:Organization
Organization Name:CROSS TRAILS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-339-1196
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63730-0039
Mailing Address - Country:US
Mailing Address - Phone:573-722-3034
Mailing Address - Fax:573-722-3244
Practice Address - Street 1:307 GABRIEL ST.
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:MO
Practice Address - Zip Code:63730
Practice Address - Country:US
Practice Address - Phone:573-722-3034
Practice Address - Fax:573-722-3244
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSS TRAILS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-18
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508082823Medicaid
MO000012446Medicare PIN
MO508082823Medicaid