Provider Demographics
NPI:1790953909
Name:MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Entity Type:Organization
Organization Name:MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Other - Org Name:ST. CLAIR CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:P
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:314-286-2025
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE. 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-7644
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:875 N COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-1118
Practice Address - Country:US
Practice Address - Phone:636-629-7467
Practice Address - Fax:636-629-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty