Provider Demographics
NPI:1235228222
Name:MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Entity Type:Organization
Organization Name:MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Other - Org Name:SULLIVAN MEDICAL OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHWARM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-468-1343
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-7644
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:965 MATTOX DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2365
Practice Address - Country:US
Practice Address - Phone:573-486-4186
Practice Address - Fax:314-996-3610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO355-24261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCE7443OtherMEDICARE RAILROAD
MOCG2664OtherMEDICARE RAILROAD
MOCG2664OtherMEDICARE RAILROAD
MO263487Medicare Oscar/Certification