Provider Demographics
NPI:1447430574
Name:PHELPS COUNTY REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:PHELPS COUNTY REGIONAL MEDICAL CENTER
Other - Org Name:PHELPS HEALTH MEDICAL GROUP WAYNESVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/SR. VP
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-458-7916
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0579
Mailing Address - Country:US
Mailing Address - Phone:573-426-2182
Mailing Address - Fax:573-426-5341
Practice Address - Street 1:1000 GW LANE
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-5401
Practice Address - Country:US
Practice Address - Phone:573-774-2715
Practice Address - Fax:573-774-2792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007024375208000000X
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO596499509Medicaid
MO596499509Medicaid
MO263826Medicare Oscar/Certification