Provider Demographics
NPI:1619090404
Name:CEDAR COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CEDAR COUNTY MEMORIAL HOSPITAL
Other - Org Name:PROFESSIONAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-876-2511
Mailing Address - Street 1:1401 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64744-2037
Mailing Address - Country:US
Mailing Address - Phone:417-876-2511
Mailing Address - Fax:417-876-3812
Practice Address - Street 1:1401 S PARK ST
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744-2037
Practice Address - Country:US
Practice Address - Phone:417-876-2511
Practice Address - Fax:417-876-3812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO540325305Medicaid