Healthcare Provider Details

I. General information

NPI: 1891201331
Provider Name (Legal Business Name): PIKE COUNTY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 N GALLOWAY RD
VANDALIA MO
63382-1259
US

IV. Provider business mailing address

2305 GEORGIA ST
LOUISIANA MO
63353-2559
US

V. Phone/Fax

Practice location:
  • Phone: 573-594-2111
  • Fax:
Mailing address:
  • Phone: 573-754-5531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN SELLE
Title or Position: CEO
Credential:
Phone: 573-754-5531