Provider Demographics
NPI:1033895628
Name:CROSS TRAILS MEDICAL CENTER
Entity type:Organization
Organization Name:CROSS TRAILS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-332-0808
Mailing Address - Street 1:408 S BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5725
Mailing Address - Country:US
Mailing Address - Phone:573-332-0808
Mailing Address - Fax:573-339-7945
Practice Address - Street 1:2430 GOLDEN STREET
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-339-1196
Practice Address - Fax:573-339-9378
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSS TRAILS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)