Healthcare Provider Details

I. General information

NPI: 1114172111
Provider Name (Legal Business Name): KENNETT HMA PHYSICIAN MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 1ST ST
KENNETT MO
63857-2525
US

IV. Provider business mailing address

1231 1ST ST SUITE 8
KENNETT MO
63857-2527
US

V. Phone/Fax

Practice location:
  • Phone: 573-888-8424
  • Fax: 573-888-2715
Mailing address:
  • Phone: 573-888-8424
  • Fax: 573-888-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MS. MICHELLE M BEACHAM
Title or Position: CONTROLLER
Credential:
Phone: 573-888-8424