=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639177561
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALEM MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2005
-----------------------------------------------------
Last Update Date | 01/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35629 HIGHWAY 72
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65560-7217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-729-6626
-----------------------------------------------------
Fax | 573-729-6502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 774
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65560-0774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-729-6626
-----------------------------------------------------
Fax | 573-729-6502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. DENNIS P PRYOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-729-6626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | 58567
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------