1528348778 NPI number — SOUTHEAST MISSOURI HEALTH NETWORK

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 1528348778 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:
Provider Other Organization Name Type Code:
6
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:
1528348778
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 SEMO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW MADRID
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63869-1734
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:
6724 HIGHWAY 77 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-545-4191
Provider Business Practice Location Address Fax Number:
573-545-4425
Provider Enumeration Date:
08/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
573-748-2404

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1497035661 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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