Healthcare Provider Details

I. General information

NPI: 1053659904
Provider Name (Legal Business Name): SOUTHEASTHEALTH HOSPITAL HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 KANELL BLVD
POPLAR BLUFF MO
63901-4045
US

IV. Provider business mailing address

PO BOX 989
POPLAR BLUFF MO
63902-0989
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-0020
  • Fax: 573-776-7548
Mailing address:
  • Phone: 573-778-0020
  • Fax: 573-776-7548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PAULA E HARRIS
Title or Position: VP REGIONAL OPERATIONS
Credential:
Phone: 573-778-0020