=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982699328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERRY COUNTY HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2005
-----------------------------------------------------
Last Update Date | 06/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 434 N WEST ST
-----------------------------------------------------
City | PERRYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63775-1359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-547-2530
-----------------------------------------------------
Fax | 573-517-0347
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 434 N WEST ST
-----------------------------------------------------
City | PERRYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63775-1359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-547-2530
-----------------------------------------------------
Fax | 573-517-0347
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MICHAEL ELLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-768-3207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | 442-7
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------