Provider Demographics
NPI:1225338155
Name:SGOH ACQUISITION, INC.
Entity Type:Organization
Organization Name:SGOH ACQUISITION, INC.
Other - Org Name:OCH WELLPOINTE FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-837-4090
Mailing Address - Street 1:2828 N NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4306
Mailing Address - Country:US
Mailing Address - Phone:417-837-4000
Mailing Address - Fax:
Practice Address - Street 1:543 W HUBBLE DR
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-1532
Practice Address - Country:US
Practice Address - Phone:417-859-4878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268672Medicare PIN