Provider Demographics
NPI:1497763361
Name:MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Entity Type:Organization
Organization Name:MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Other - Org Name:MISSOURI BAPTIST SULLIVAN HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHWARM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-468-1343
Mailing Address - Street 1:751 SAPPINGTON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2354
Mailing Address - Country:US
Mailing Address - Phone:573-468-1343
Mailing Address - Fax:573-860-2696
Practice Address - Street 1:751 SAPPINGTON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2354
Practice Address - Country:US
Practice Address - Phone:573-468-4186
Practice Address - Fax:573-860-2696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO355-24273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
108OtherBLUE CROSS-BLUE SHIELD
MO800565004Medicaid
489665OtherAETNA
MOMI010565000Medicaid
108OtherBLUE CHOICE
260115OtherPREMIER PLUS
MO540565009Medicaid
=========OtherUNITED HEALTHCARE
=========OtherHEALTHCARE USA
=========OtherMERCY MC+
108OtherBLUE CROSS-BLUE SHIELD
489665OtherAETNA
=========OtherTRICARE
108OtherBLUE CHOICE
=========OtherGHP