Provider Demographics
NPI:1962565499
Name:CROSS TRAILS MEDICAL CENTER
Entity type:Organization
Organization Name:CROSS TRAILS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-339-1196
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764-0349
Mailing Address - Country:US
Mailing Address - Phone:573-238-2725
Mailing Address - Fax:573-238-3795
Practice Address - Street 1:109 HWY 51 NORTH
Practice Address - Street 2:
Practice Address - City:MARBLE HILL
Practice Address - State:MO
Practice Address - Zip Code:63764
Practice Address - Country:US
Practice Address - Phone:573-238-2725
Practice Address - Fax:573-238-3795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSS TRAILS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCD9626OtherRAILROAD MEDICARE
MO508082815Medicaid
MO000012446Medicare PIN
MO508082815Medicaid