Provider Demographics
NPI:1902153539
Name:STE GENEVIEVE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:STE GENEVIEVE COUNTY MEMORIAL HOSPITAL
Other - Org Name:BLOOMSDALE REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-883-7703
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-0468
Mailing Address - Country:US
Mailing Address - Phone:573-883-4488
Mailing Address - Fax:573-883-4472
Practice Address - Street 1:255 BODERMAN
Practice Address - Street 2:SUITE 1C
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627
Practice Address - Country:US
Practice Address - Phone:573-883-4473
Practice Address - Fax:573-883-4472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010491801Medicaid