Healthcare Provider Details

I. General information

NPI: 1336381755
Provider Name (Legal Business Name): MCCUNE BROOKS REGIONAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 BUENA VISTA AVE
CARTHAGE MO
64836-3178
US

IV. Provider business mailing address

1911 BUENA VISTA AVE
CARTHAGE MO
64836-3178
US

V. Phone/Fax

Practice location:
  • Phone: 417-237-0983
  • Fax: 417-237-0997
Mailing address:
  • Phone: 417-237-0983
  • Fax: 417-237-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number100685
License Number StateMO

VIII. Authorized Official

Name: MR. ROBERT Y COPELAND
Title or Position: CEO
Credential:
Phone: 417-358-8121