Provider Demographics
NPI:1710056213
Name:DEXTER HOSPITAL LLC
Entity Type:Organization
Organization Name:DEXTER HOSPITAL LLC
Other - Org Name:JIBBEN MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-624-1640
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-0368
Mailing Address - Country:US
Mailing Address - Phone:573-624-3165
Mailing Address - Fax:573-624-3157
Practice Address - Street 1:1525 W BUSINESS HWY 60
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841
Practice Address - Country:US
Practice Address - Phone:573-624-8447
Practice Address - Fax:573-624-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504910001Medicaid
MODC5219OtherMEDICARE RAILROAD
MODC5219OtherMEDICARE RAILROAD
MO268620Medicare Oscar/Certification