Healthcare Provider Details

I. General information

NPI: 1477997567
Provider Name (Legal Business Name): SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 01/13/2024
Certification Date: 01/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ONE MILE ROAD
DEXTER MO
63841-1000
US

IV. Provider business mailing address

PO BOX 368
DEXTER MO
63841-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-614-1900
  • Fax: 573-624-8895
Mailing address:
  • Phone: 573-614-1900
  • Fax: 573-625-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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