Provider Demographics
NPI:1598737827
Name:WASHINGTON COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WASHINGTON COUNTY MEMORIAL HOSPITAL
Other - Org Name:HEALTH WAY PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-438-5451
Mailing Address - Street 1:200 HEALTH WAY DR
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1434
Mailing Address - Country:US
Mailing Address - Phone:573-438-2977
Mailing Address - Fax:573-438-5460
Practice Address - Street 1:200 HEALTH WAY DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1434
Practice Address - Country:US
Practice Address - Phone:573-438-2977
Practice Address - Fax:573-438-5460
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WASHINGTON COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-02
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6P28207Q00000X
MO2002028056207Q00000X
261QR1300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO596896704Medicaid
MO506896703Medicaid
MO506896703Medicaid
MO000012288Medicare ID - Type UnspecifiedMEDICARE PART B