Provider Demographics
NPI:1912023441
Name:LACROIX MEDICAL CENTER
Entity Type:Organization
Organization Name:LACROIX MEDICAL CENTER
Other - Org Name:RODERIC C CRIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERIC
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:CRIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-339-0004
Mailing Address - Street 1:3095 LEXINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2602
Mailing Address - Country:US
Mailing Address - Phone:573-339-0004
Mailing Address - Fax:
Practice Address - Street 1:3095 LEXINGTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2602
Practice Address - Country:US
Practice Address - Phone:573-339-0004
Practice Address - Fax:573-335-9974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2H52207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000095535Medicare ID - Type Unspecified
MOE59394Medicare UPIN