Provider Demographics
NPI:1548520026
Name:SSM AUDRAIN HEALTH CARE, INC.
Entity type:Organization
Organization Name:SSM AUDRAIN HEALTH CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:VANCONIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-582-8108
Mailing Address - Street 1:221 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:MO
Mailing Address - Zip Code:65275-1328
Mailing Address - Country:US
Mailing Address - Phone:660-327-4000
Mailing Address - Fax:660-327-4007
Practice Address - Street 1:221 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:MO
Practice Address - Zip Code:65275-1328
Practice Address - Country:US
Practice Address - Phone:660-327-4000
Practice Address - Fax:660-327-4007
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM AUDRAIN HEALTH CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-18
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1548520026Medicaid
MO1548520026Medicaid