Provider Demographics
NPI:1194749713
Name:CEDAR COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:CEDAR COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-876-2511
Mailing Address - Street 1:1401 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64744-2037
Mailing Address - Country:US
Mailing Address - Phone:417-876-2511
Mailing Address - Fax:417-876-3812
Practice Address - Street 1:807 OWENS MILL RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:MO
Practice Address - Zip Code:65785-8359
Practice Address - Country:US
Practice Address - Phone:417-276-5500
Practice Address - Fax:417-876-3812
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CEDAR COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-27
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268507Medicare ID - Type Unspecified