{
"Npi": {
"NPI": "1316240096",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "500 N DOUGLASS ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MALDEN",
"MailingAddressStateName": "MO",
"MailingAddressPostalCode": "63863-1506",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "573-276-2221",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "500 N DOUGLASS ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MALDEN",
"PracticeLocationAddressStateName": "MO",
"PracticeLocationAddressPostalCode": "63863-1506",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "573-276-2221",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "12/17/2010",
"LastUpdateDate": "09/16/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BERRY",
"AuthorizedOfficialFirstName": "KRISTA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CFO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "573-331-6028",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207Q00000X",
"TaxonomyName": "Family Medicine Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QR1300X",
"TaxonomyName": "Rural Health Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}