Provider Demographics
NPI:1275504797
Name:MOBERLY HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:MOBERLY HOSPITAL COMPANY LLC
Other - Org Name:MOBERLY REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP, GROUP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTACCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-373-9600
Mailing Address - Street 1:PO BOX 60856
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 UNION AVE
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9407
Practice Address - Country:US
Practice Address - Phone:660-263-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOBERLY HOSPITAL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-01
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO423-9314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110450OtherBLUE CROSS
MO110450OtherBLUE CROSS