Provider Demographics
NPI:1689004103
Name:MEDICAL WEST HEALTHCARE CENTER LLC
Entity Type:Organization
Organization Name:MEDICAL WEST HEALTHCARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-441-8876
Mailing Address - Street 1:1019 TOWN DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:KY
Mailing Address - Zip Code:41076-9114
Mailing Address - Country:US
Mailing Address - Phone:859-441-8876
Mailing Address - Fax:
Practice Address - Street 1:4630 MEXICO RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1607
Practice Address - Country:US
Practice Address - Phone:636-477-1888
Practice Address - Fax:636-477-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO18411550332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO626100101Medicaid
MO181658OtherBLUE CROSS BLUE SHIELD OF MISSOURI
MO612829OtherHEALTHLINK
MO626100101Medicaid
MO626100101Medicaid