MEDICARE: NORTHEAST MISSOURI HEALTH COUNCIL, INC

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	:	1487038881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST MISSOURI HEALTH COUNCIL, INC

Provider Business Mailing Address
First Line	:	1416 CROWN DR
Second Line	:
City	:	KIRKSVILLE
State	:	MO
Zip	:	63501-2548
Country	:	US
Telephone Number	:	660-627-5757
Fax Number	:	660-627-5802

Provider Business Practice Location Address
First Line	:	209 N MISSOURI ST
Second Line	:
City	:	MACON
State	:	MO
Zip	:	63552-2151
Country	:	US
Telephone Number	:	660-395-5045
Fax Number	:	660-395-5048

Authorized Official
Title or Position	:	CEO
Name	:	ANDREW H GRIMM
Credential	:
Telephone Number	:	660-627-5757

Provider Enumeration Date	:	07/15/2015
Last Update Date	:	11/11/2015

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