1780803916 NPI number — SOUTHEAST MISSOURI HEALTH NETWORK

Table of content: (NPI 1780803916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780803916 NPI number — SOUTHEAST MISSOURI HEALTH NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MISSOURI HEALTH NETWORK
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:
PORTAGEVILLE FAMILY CLINIC
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:
1780803916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 MAIN ST
Provider Second Line Business Mailing Address:
P.O. BOX 400
Provider Business Mailing Address City Name:
NEW MADRID
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63869-1942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-748-2404
Provider Business Mailing Address Fax Number:
573-748-8929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGEVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63873-1616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-379-5929
Provider Business Practice Location Address Fax Number:
573-379-5912
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
573-748-2404

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010626 . This is a "GROUP PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 503973901 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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