Provider Demographics
NPI:1467462010
Name:SSM AUDRAIN HEALTH CARE, INC.
Entity Type:Organization
Organization Name:SSM AUDRAIN HEALTH CARE, INC.
Other - Org Name:SSM HEALTH MEDICAL GROUP - FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:VANCONIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-582-8108
Mailing Address - Street 1:626 E SUMMIT ST STE L
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3298
Mailing Address - Country:US
Mailing Address - Phone:573-581-6266
Mailing Address - Fax:573-581-0955
Practice Address - Street 1:626 E SUMMIT ST STE L
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3298
Practice Address - Country:US
Practice Address - Phone:573-581-6266
Practice Address - Fax:573-581-0955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM AUDRAIN HEALTH CARE. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO597765809Medicaid
MO507765808Medicaid
MO597765809Medicaid
MO507765808Medicaid