MEDICARE: DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, 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	:	1598762593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 216
Second Line	:
City	:	GAINESVILLE
State	:	MO
Zip	:	65655-0216
Country	:	US
Telephone Number	:	417-679-2775
Fax Number	:	417-679-2633

Provider Business Practice Location Address
First Line	:	201 ELM ST
Second Line	:
City	:	GAINESVILLE
State	:	MO
Zip	:	65655-9998
Country	:	US
Telephone Number	:	417-679-2775
Fax Number	:	417-679-2633

Authorized Official
Title or Position	:	CEO
Name	:	MR. RICHARD R SIMS
Credential	:
Telephone Number	:	417-683-4831

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	01/09/2008

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