Provider Demographics
NPI:1912190620
Name:NORTHWEST MEDICAL CENTER ASSOCIATION, INC.
Entity Type:Organization
Organization Name:NORTHWEST MEDICAL CENTER ASSOCIATION, INC.
Other - Org Name:MOSAIC FAMILY CARE ALBANY EAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOOLITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-726-3941
Mailing Address - Street 1:1607 E US HIGHWAY 136
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MO
Mailing Address - Zip Code:64402-8223
Mailing Address - Country:US
Mailing Address - Phone:660-726-3333
Mailing Address - Fax:660-726-3232
Practice Address - Street 1:1607 E US HIGHWAY 136
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MO
Practice Address - Zip Code:64402-8223
Practice Address - Country:US
Practice Address - Phone:660-726-3333
Practice Address - Fax:660-726-3232
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST MEDICAL CENTER ASSOCIATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-27
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505708305Medicaid
MO203818505Medicaid
MOL288375OtherMEDICARE PART B GROUP #