1669493144 NPI number — PEMISCOT COUNTY MEMORIAL HOSPITAL

Table of content: (NPI 1669493144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669493144 NPI number — PEMISCOT COUNTY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEMISCOT 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:
CARUTHERSVILLE NURSING CENTER
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:
1669493144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 TRUMAN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARUTHERSVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63830-1261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-333-5150
Provider Business Mailing Address Fax Number:
573-333-4580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 TRUMAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARUTHERSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63830-1261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-333-5150
Provider Business Practice Location Address Fax Number:
573-333-4580
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NOBLE
Authorized Official First Name:
KERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
573-359-3612

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  032389 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 032389 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101459006 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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