1447412770 NPI number — TEXAS COUNTY MEMORIAL HOSPITAL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447412770 NPI number — TEXAS COUNTY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS COUNTY MEMORIAL HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TCMH FAMILY CLINIC - LICKING
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447412770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 47
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LICKING
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65542-0047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-674-3011
Provider Business Mailing Address Fax Number:
573-674-4765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LICKING
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-674-3011
Provider Business Practice Location Address Fax Number:
573-674-4765
Provider Enumeration Date:
06/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PAMPERIEN
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
417-967-3311

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 26D0679044 . This is a "CLIA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1447412770 . This is a "RH - MEDICAID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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