Healthcare Provider Details

I. General information

NPI: 1881730893
Provider Name (Legal Business Name): NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E JACKSON ST
EDINA MO
63537-1335
US

IV. Provider business mailing address

1416 CROWN DR
KIRKSVILLE MO
63501-2548
US

V. Phone/Fax

Practice location:
  • Phone: 660-397-3517
  • Fax: 660-397-2307
Mailing address:
  • Phone: 660-627-5757
  • Fax: 660-627-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number107529
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9D62
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateMO

VIII. Authorized Official

Name: ANDREW H. GRIMM
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 660-627-5757