=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932372646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEMISCOT COUNTY MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2008
-----------------------------------------------------
Last Update Date | 06/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 VIRGINIA AVE
-----------------------------------------------------
City | NEW MADRID
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-748-3107
-----------------------------------------------------
Fax | 573-748-3112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 442
-----------------------------------------------------
City | HAYTI
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63851-0442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-359-3659
-----------------------------------------------------
Fax | 573-359-3608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING DIRECTOR
-----------------------------------------------------
Name | CATHY LACEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-359-3659
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------