Provider Demographics
NPI: | 1487865945 |
---|---|
Name: | OMC FEE FOR SERVICE |
Entity Type: | Organization |
Organization Name: | OMC FEE FOR SERVICE |
Other - Org Name: | OZARKS MEDICAL CENTER |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT AND CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | PHILIP |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BAGBY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 417-256-9111 |
Mailing Address - Street 1: | PO BOX 1100 |
Mailing Address - Street 2: | |
Mailing Address - City: | WEST PLAINS |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 65775-1100 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1100 N KENTUCKY AVE |
Practice Address - Street 2: | |
Practice Address - City: | WEST PLAINS |
Practice Address - State: | MO |
Practice Address - Zip Code: | 65775-2029 |
Practice Address - Country: | US |
Practice Address - Phone: | 417-257-6701 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-05-25 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 17448 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty |