Provider Demographics
NPI:1033183819
Name:JESSE DWAYNE HELTON
Entity Type:Organization
Organization Name:JESSE DWAYNE HELTON
Other - Org Name:BYRNES MILL MEDICAL CENTER-RICHWOODS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:HELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-678-2444
Mailing Address - Street 1:10649 STATE HIGHWAY A
Mailing Address - Street 2:PO BOX 280
Mailing Address - City:RICHWOODS
Mailing Address - State:MO
Mailing Address - Zip Code:63071-2558
Mailing Address - Country:US
Mailing Address - Phone:573-678-2444
Mailing Address - Fax:573-678-2445
Practice Address - Street 1:10649 STATE HIGHWAY A
Practice Address - Street 2:
Practice Address - City:RICHWOODS
Practice Address - State:MO
Practice Address - Zip Code:63071-2558
Practice Address - Country:US
Practice Address - Phone:573-678-2444
Practice Address - Fax:573-678-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6F69207Q00000X
MO2006025334207Q00000X
MODO113093207R00000X
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D1024953OtherCLIA
MO506296607Medicaid
MO595379314Medicaid
MO000094772Medicare PIN