Healthcare Provider Details

I. General information

NPI: 1598069247
Provider Name (Legal Business Name): SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 S WALNUT ST
BERNIE MO
63822-8900
US

IV. Provider business mailing address

741 SOUTH WALNUT
BERNIE MO
63822
US

V. Phone/Fax

Practice location:
  • Phone: 573-293-6930
  • Fax: 573-293-6841
Mailing address:
  • Phone: 573-293-6930
  • Fax: 573-293-6841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. SARA DEANE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 573-313-2500