MEDICARE: GREAT MINES HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1003551797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT MINES HEALTH CENTER

Provider Business Mailing Address
First Line	:	1 SOUTHTOWNE DR
Second Line	:
City	:	POTOSI
State	:	MO
Zip	:	63664-5729
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 REBEL DR RM 201
Second Line	:
City	:	PARK HILLS
State	:	MO
Zip	:	63601-2508
Country	:	US
Telephone Number	:	573-431-2616
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	GREGORY A ROEBACK
Credential	:
Telephone Number	:	573-438-8380

Provider Enumeration Date	:	04/28/2022
Last Update Date	:	04/28/2022

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Directions to “GREAT MINES HEALTH CENTER ” Practice Location

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