Healthcare Provider Details

I. General information

NPI: 1235275249
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: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 55 SIGLER AVENUE
MEMPHIS MO
63555-9726
US

IV. Provider business mailing address

314 E MCPHERSON ST
KIRKSVILLE MO
63501-3557
US

V. Phone/Fax

Practice location:
  • Phone: 660-465-7037
  • Fax: 660-465-7350
Mailing address:
  • Phone: 660-627-5757
  • Fax: 660-627-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number076376
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2001023603
License Number StateMO

VIII. Authorized Official

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