Healthcare Provider Details

I. General information

NPI: 1982905295
Provider Name (Legal Business Name): SOUTHEAST HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 S MOUNT AUBURN RD STE 130
CAPE GIRARDEAU MO
63703-6392
US

IV. Provider business mailing address

817 S MOUNT AUBURN RD STE 130
CAPE GIRARDEAU MO
63703-6392
US

V. Phone/Fax

Practice location:
  • Phone: 573-519-4550
  • Fax: 573-519-4590
Mailing address:
  • Phone: 573-519-4550
  • Fax: 573-519-4590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2010038132
License Number StateMO

VIII. Authorized Official

Name: KRISTA BERRY
Title or Position: CFO
Credential:
Phone: 573-331-6028