Provider Demographics
NPI:1619963972
Name:INDEPENDENCE HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:INDEPENDENCE HEALTH SYSTEM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHNURBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-547-6546
Mailing Address - Street 1:800 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-2106
Mailing Address - Country:US
Mailing Address - Phone:573-547-6546
Mailing Address - Fax:573-547-2823
Practice Address - Street 1:800 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-2106
Practice Address - Country:US
Practice Address - Phone:573-547-6546
Practice Address - Fax:573-547-2823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031348310400000X
MO031654314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101493203Medicaid
MO268114808Medicaid
MO265829Medicare Oscar/Certification