Provider Demographics
NPI:1275102824
Name:BIG SPRINGS MEDICAL ASSOCIATION
Entity Type:Organization
Organization Name:BIG SPRINGS MEDICAL ASSOCIATION
Other - Org Name:WAYNE COUNTY DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-663-2313
Mailing Address - Street 1:110 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-9400
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:573-663-2441
Practice Address - Street 1:1 HALS PLZ STE B
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-1613
Practice Address - Country:US
Practice Address - Phone:573-223-8902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BIG SPRINGS MEDICAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-18
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)