Provider Demographics
NPI:1245208875
Name:HOSPITAL OF FULTON, INC.
Entity Type:Organization
Organization Name:HOSPITAL OF FULTON, INC.
Other - Org Name:HICKMAN-FULTON COUNTY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTH OFF / DIR BUSINESS OF FICE SUP
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:PO BOX 60985
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0985
Mailing Address - Country:US
Mailing Address - Phone:270-236-3202
Mailing Address - Fax:270-236-9597
Practice Address - Street 1:2003 S 7TH ST
Practice Address - Street 2:
Practice Address - City:HICKMAN
Practice Address - State:KY
Practice Address - Zip Code:42050-1841
Practice Address - Country:US
Practice Address - Phone:270-236-3202
Practice Address - Fax:270-236-9597
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL OF FULTON, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-09
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363L00000X, 367500000X
KY900142261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35001387Medicaid
KY295172OtherBCBS
KY295172OtherBCBS
18-3449Medicare ID - Type Unspecified
KY183449Medicare Oscar/Certification