Provider Demographics
NPI:1396827804
Name:ST. CLAIR COUNTY HOSPITAL DISTRICT NO. 1
Entity Type:Organization
Organization Name:ST. CLAIR COUNTY HOSPITAL DISTRICT NO. 1
Other - Org Name:SAC-OSAGE HOSPITAL TRI-COUNTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-646-8181
Mailing Address - Street 1:855 ARDUSER DR
Mailing Address - Street 2:P.O. BOX 560
Mailing Address - City:OSCEOLA
Mailing Address - State:MO
Mailing Address - Zip Code:64776-6278
Mailing Address - Country:US
Mailing Address - Phone:417-646-8153
Mailing Address - Fax:417-646-8515
Practice Address - Street 1:855 ARDUSER DR
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:MO
Practice Address - Zip Code:64776-6278
Practice Address - Country:US
Practice Address - Phone:417-646-8153
Practice Address - Fax:417-646-8515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO24238261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268556Medicare ID - Type UnspecifiedMEDICARE RHC #