Provider Demographics
NPI:1992878177
Name:COUNTY OF COLE
Entity type:Organization
Organization Name:COUNTY OF COLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDING COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-636-2181
Mailing Address - Street 1:3400 W TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5712
Mailing Address - Country:US
Mailing Address - Phone:573-636-2181
Mailing Address - Fax:573-636-3851
Practice Address - Street 1:3400 W TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5712
Practice Address - Country:US
Practice Address - Phone:573-636-2181
Practice Address - Fax:573-636-3851
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF COLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-16
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO510903909Medicaid
MO428178511Medicaid
MO425440500Medicaid
MO000045065Medicare ID - Type Unspecified