Provider Demographics
NPI:1730215195
Name:OZARKS MEDICAL CENTER
Entity type:Organization
Organization Name:OZARKS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-256-9111
Mailing Address - Street 1:1375 NETTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:MO
Mailing Address - Zip Code:65791-8740
Mailing Address - Country:US
Mailing Address - Phone:417-264-7136
Mailing Address - Fax:417-264-7122
Practice Address - Street 1:1375 NETTLETON AVENUE
Practice Address - Street 2:
Practice Address - City:THAYER
Practice Address - State:MO
Practice Address - Zip Code:65791
Practice Address - Country:US
Practice Address - Phone:417-264-7136
Practice Address - Fax:417-264-7122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OZARKS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-27
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO17447261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126733729Medicaid
MO597843309Medicaid
263438Medicare Oscar/Certification