Healthcare Provider Details

I. General information

NPI: 1205883980
Provider Name (Legal Business Name): KENNETT HMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 1ST ST
KENNETT MO
63857-2525
US

IV. Provider business mailing address

PO BOX 281375
ATLANTA GA
30384-1375
US

V. Phone/Fax

Practice location:
  • Phone: 573-888-8421
  • Fax: 573-888-5525
Mailing address:
  • Phone: 573-888-8421
  • Fax: 573-888-5525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number4861
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier010492809
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
Identifier184
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerBLUE CROSS

VIII. Authorized Official

Name: PAULA M LALOR
Title or Position: DIRECTOR/DELEGATED OFFICIAL
Credential:
Phone: 615-925-4565