Healthcare Provider Details

I. General information

NPI: 1649697566
Provider Name (Legal Business Name): SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARUTHERSVILLE MEDICAL CENTER 109 EAST 5TH STREET
CARUTHERSVILLE MO
63830-1417
US

IV. Provider business mailing address

6738 STATE HIGHWAY 77
BENTON MO
63736-8238
US

V. Phone/Fax

Practice location:
  • Phone: 573-359-9803
  • Fax: 573-359-0990
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: MS. SARAH DEANE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 573-313-2500