=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073595096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-SOUTH HEALTH CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2005
-----------------------------------------------------
Last Update Date | 07/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 WARRIOR LN
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-8686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-785-0851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 E CENTER DR
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-5931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-465-7717
-----------------------------------------------------
Fax | 618-465-7710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JOETTA MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-785-0851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | 031640
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------