Provider Demographics
NPI:1598239790
Name:MOSAIC MEDICAL CENTER - MARYVILLE
Entity Type:Organization
Organization Name:MOSAIC MEDICAL CENTER - MARYVILLE
Other - Org Name:MOSAIC SPECIALTY CARE - EAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBUREMENT
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-273-0473
Mailing Address - Street 1:114 E SOUTH HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2659
Mailing Address - Country:US
Mailing Address - Phone:660-562-2525
Mailing Address - Fax:660-562-4303
Practice Address - Street 1:114 E SOUTH HILLS DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2659
Practice Address - Country:US
Practice Address - Phone:660-562-2525
Practice Address - Fax:660-562-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty