Healthcare Provider Details

I. General information

NPI: 1194945154
Provider Name (Legal Business Name): SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 S WALNUT ST
BERNIE MO
63822-8900
US

IV. Provider business mailing address

6738 STATE HIGHWAY 77
BENTON MO
63736-8238
US

V. Phone/Fax

Practice location:
  • Phone: 573-748-7712
  • Fax: 573-293-6838
Mailing address:
  • Phone: 573-313-2500
  • Fax: 573-313-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

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