Healthcare Provider Details

I. General information

NPI: 1326184334
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: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W JEFFERSON ST
KIRKSVILLE MO
63501-3407
US

IV. Provider business mailing address

1416 CROWN DR
KIRKSVILLE MO
63501-2548
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-3555
  • Fax:
Mailing address:
  • Phone: 660-627-5757
  • Fax: 660-627-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberR5810
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2004027805
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2009006697
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006022612
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2005037590
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number2009001623
License Number StateMO

VIII. Authorized Official

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