Provider Demographics
NPI:1891909552
Name:CITIZENS MEMORIAL HEALTHCARE
Entity Type:Organization
Organization Name:CITIZENS MEMORIAL HEALTHCARE
Other - Org Name:CMH EYE SPECIALTY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DONA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLISPIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-328-7243
Mailing Address - Street 1:1155 W. PARKVIEW ST.
Mailing Address - Street 2:SUITE 1 B
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-7800
Mailing Address - Country:US
Mailing Address - Phone:417-777-2222
Mailing Address - Fax:417-777-2224
Practice Address - Street 1:1155 W. PARKVIEW ST.
Practice Address - Street 2:SUITE 1 B
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-7800
Practice Address - Country:US
Practice Address - Phone:417-777-2222
Practice Address - Fax:417-777-2224
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITIZENS MEMORIAL HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-10
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506997907Medicaid