Provider Demographics
NPI:1629132790
Name:DEXTER HOSPITAL LLC
Entity Type:Organization
Organization Name:DEXTER HOSPITAL LLC
Other - Org Name:MSH GENER AL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-614-1951
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841
Mailing Address - Country:US
Mailing Address - Phone:573-624-3165
Mailing Address - Fax:573-624-3157
Practice Address - Street 1:1300 N ONE MILE RD
Practice Address - Street 2:SUITE 7
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841
Practice Address - Country:US
Practice Address - Phone:573-624-9936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507576106Medicaid
MODC5219OtherRAILROAD MEDICARE
000014334Medicare ID - Type Unspecified