Healthcare Provider Details

I. General information

NPI: 1699050658
Provider Name (Legal Business Name): SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 NORTH MARKET STREET
SENATH MO
63876
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: 573-748-2440
  • Fax:
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 State

VIII. Authorized Official

Name: CHRISTA TUCKER
Title or Position: CFO
Credential:
Phone: 573-748-2404