Healthcare Provider Details

I. General information

NPI: 1396718649
Provider Name (Legal Business Name): KIRKSVILLE MISSOURI HOSPTIAL COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S OSTEOPATHY
KIRKSVILLE MO
63501-6401
US

IV. Provider business mailing address

PO BOX 503525
SAINT LOUIS MO
63150-3525
US

V. Phone/Fax

Practice location:
  • Phone: 660-785-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number462-4
License Number StateMO

VIII. Authorized Official

Name: MICHAEL PORTACCI
Title or Position: SENIOR VP, GROUP OPERATIONS
Credential:
Phone: 888-373-9600