Provider Demographics
NPI:1316140494
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 S HIGHWAY 65
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:660-886-7431
Mailing Address - Fax:660-886-9001
Practice Address - Street 1:600 W MORRISON ST
Practice Address - Street 2:SUITE 5
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1075
Practice Address - Country:US
Practice Address - Phone:660-248-2900
Practice Address - Fax:660-248-1544
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN FITZGIBBON MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-07
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QP2300X
MO27-56261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503959108Medicaid
MO0000 13071Medicare PIN
MO503959108Medicaid