Provider Demographics
NPI:1679600936
Name:OZARKS MEDICAL CENTER
Entity Type:Organization
Organization Name:OZARKS MEDICAL CENTER
Other - Org Name:SALEM 1ST CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-257-9111
Mailing Address - Street 1:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1100
Mailing Address - Country:US
Mailing Address - Phone:870-895-1911
Mailing Address - Fax:870-895-4244
Practice Address - Street 1:172 HWY 62 EAST
Practice Address - Street 2:SUITE 1
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576
Practice Address - Country:US
Practice Address - Phone:870-895-1911
Practice Address - Fax:870-895-4244
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OZARKS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-27
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO17447261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR118739729Medicaid
MO592967509Medicaid
AR043975Medicare Oscar/Certification