Provider Demographics
NPI:1801021142
Name:BIG SPRINGS MEDICAL ASSOCIATION
Entity Type:Organization
Organization Name:BIG SPRINGS MEDICAL ASSOCIATION
Other - Org Name:WAYNE COUNTY MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHERILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-663-2313
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:573-663-2441
Practice Address - Street 1:135 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MO
Practice Address - Zip Code:63944
Practice Address - Country:US
Practice Address - Phone:573-224-3660
Practice Address - Fax:573-224-3770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BIG SPRINGS MEDICAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-15
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000010497OtherSTATE MEDICARE
MO1801021142Medicaid
261036Medicare Oscar/Certification