Provider Demographics
| NPI: | 1568566131 |
|---|---|
| Name: | CITIZENS MEMORIAL HEALTHCARE |
| Entity Type: | Organization |
| Organization Name: | CITIZENS MEMORIAL HEALTHCARE |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CHIEF EXECUTIVE OFFICER |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | DONALD |
| Authorized Official - Middle Name: | J |
| Authorized Official - Last Name: | BABB |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | CEO |
| Authorized Official - Phone: | 417-328-6501 |
| Mailing Address - Street 1: | 1500 N OAKLAND AVE |
| Mailing Address - Street 2: | |
| Mailing Address - City: | BOLIVAR |
| Mailing Address - State: | MO |
| Mailing Address - Zip Code: | 65613-3011 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 417-328-6501 |
| Mailing Address - Fax: | 417-328-6338 |
| Practice Address - Street 1: | 1500 N OAKLAND AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | BOLIVAR |
| Practice Address - State: | MO |
| Practice Address - Zip Code: | 65613-3011 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 417-326-6000 |
| Practice Address - Fax: | 417-328-6242 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-09-12 |
| Last Update Date: | 2017-01-05 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
| No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2081P2900X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | Group - Multi-Specialty |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MO | 5033120003 | Medicare NSC | |
| MO | DA1716 | Medicare PIN | |
| MO | 000013888 | Medicare Oscar/Certification | |
| MO | 5033120002 | Medicare NSC |
