Provider Demographics
NPI:1497705313
Name:BOTHWELL REGIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:BOTHWELL REGIONAL HEALTH CENTER
Other - Org Name:COLE CAMP CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:660-829-7790
Mailing Address - Street 1:PO BOX 801128
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1128
Mailing Address - Country:US
Mailing Address - Phone:660-668-4411
Mailing Address - Fax:660-668-4861
Practice Address - Street 1:1201 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:COLE CAMP
Practice Address - State:MO
Practice Address - Zip Code:65325-1256
Practice Address - Country:US
Practice Address - Phone:660-668-4411
Practice Address - Fax:660-668-4861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2023-05-22
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
MOE69550OtherMERCY HEALTH PLANS PIN
MO212202OtherHEALTHLINK PIN
MO4649395OtherAETNA PIN
MO507959500Medicaid
MO26-0009OtherOSCAR
MO4649395OtherAETNA PIN
MOE69550OtherMERCY HEALTH PLANS PIN
MO212202OtherHEALTHLINK PIN
MODB7468Medicare PIN
MO26-0009OtherOSCAR