MEDICARE: ELK RIVER HEALTH SERVICES, INC.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center		OK
2	261QR1300X	Rural Health Clinic/Center		MO

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1174522882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELK RIVER HEALTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 160
Second Line	:	109 N BROADWAY
City	:	SOUTH WEST CITY
State	:	MO
Zip	:	64863-0160
Country	:	US
Telephone Number	:	417-762-3287
Fax Number	:	417-762-3255

Provider Business Practice Location Address
First Line	:	109 N BROADWAY ST
Second Line	:
City	:	SOUTH WEST CITY
State	:	MO
Zip	:	64863-9417
Country	:	US
Telephone Number	:	417-762-3287
Fax Number	:	417-762-3255

Authorized Official
Title or Position	:	DIRECTOR OF CLINICS
Name	:	VICKI PLUMLEE
Credential	:
Telephone Number	:	417-762-3287

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	04/15/2014

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308