Provider Demographics
NPI:1285779330
Name:JOHN FITZGIBBON MEMORIAL HOSPITAL INC
Entity type:Organization
Organization Name:JOHN FITZGIBBON MEMORIAL HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-886-7231
Mailing Address - Street 1:2305 SOUTH 65 HIGHWAY, BUILDING A
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3702
Mailing Address - Country:US
Mailing Address - Phone:660-886-7800
Mailing Address - Fax:
Practice Address - Street 1:2305 SOUTH 65 HIGHWAY, BUILDING A
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3702
Practice Address - Country:US
Practice Address - Phone:660-886-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN FITZGIBBON MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO27-572084P0800X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268577OtherMEDICARE
MO1285779330Medicaid
MO1285779330Medicaid