Provider Demographics
NPI:1407141153
Name:CITIZENS MEMORIAL HEALTHCARE
Entity Type:Organization
Organization Name:CITIZENS MEMORIAL HEALTHCARE
Other - Org Name:SOUTHSIDE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BABB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-326-6000
Mailing Address - Street 1:1120 S SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-2512
Mailing Address - Country:US
Mailing Address - Phone:417-326-7814
Mailing Address - Fax:417-326-4059
Practice Address - Street 1:1120 S SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2512
Practice Address - Country:US
Practice Address - Phone:417-326-6000
Practice Address - Fax:417-326-4059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITIZENS MEMORIAL HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-10
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268668Medicare Oscar/Certification