Healthcare Provider Details

I. General information

NPI: 1962548974
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: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 CROWN DRIVE
KIRKSVILLE MO
63501
US

IV. Provider business mailing address

1416 CROWN DRIVE
KIRKSVILLE MO
63501-2548
US

V. Phone/Fax

Practice location:
  • Phone: 660-627-4493
  • Fax: 660-627-4288
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 Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number096968
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002241
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2006005622
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005037424
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR5E64
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR5N07
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number111208
License Number StateMO

VIII. Authorized Official

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