Provider Demographics
NPI:1962591958
Name:MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Entity type:Organization
Organization Name:MISSOURI BAPTIST HOSPITAL OF SULLIVAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT FINANCE AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:AUGUSTO
Authorized Official - Middle Name:A
Authorized Official - Last Name:NORONHA
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:314-996-5118
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-7644
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:101 PROGRESS PKWY
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2359
Practice Address - Country:US
Practice Address - Phone:573-486-3555
Practice Address - Fax:314-996-3610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO355-24261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268604Medicare Oscar/Certification
000013229Medicare PIN