Healthcare Provider Details

I. General information

NPI: 1457570681
Provider Name (Legal Business Name): SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202B MAIN ST
NEW MADRID MO
63869-1911
US

IV. Provider business mailing address

420 SEMO DR P.O. BOX 400
NEW MADRID MO
63869-1734
US

V. Phone/Fax

Practice location:
  • Phone: 573-748-5671
  • Fax: 573-748-5317
Mailing address:
  • Phone: 573-748-2404
  • Fax: 573-748-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTOPHER JONES
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 573-748-2404