Provider Demographics
NPI:1639345077
Name:BOTHWELL REGIONAL HEALTH CENTER ED
Entity type:Organization
Organization Name:BOTHWELL REGIONAL HEALTH CENTER ED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:HALSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-826-8833
Mailing Address - Street 1:PO BOX 1706
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65302-1706
Mailing Address - Country:US
Mailing Address - Phone:660-826-8833
Mailing Address - Fax:660-827-3742
Practice Address - Street 1:601 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5972
Practice Address - Country:US
Practice Address - Phone:660-826-8833
Practice Address - Fax:660-827-3742
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOTHWELL REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO540157807Medicaid
MO00185-026OtherBLUE CROSS
MO10157808Medicaid
MO00185-026OtherBLUE CROSS