1720209794 NPI number — SOUTHEAST MISSOURI HEALTH NETWORK

Table of content: (NPI 1720209794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720209794 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:
1720209794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 LINE 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:
63869-1734
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:
700 N DOUGLASS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALDEN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63863-1510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-748-7701
Provider Business Practice Location Address Fax Number:
573-748-2554
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
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: 500704028 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010626 . This is a "GROUP PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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