Provider Demographics
NPI:1053457069
Name:NORTHEAST MISSOURI HEALTH COUNCIL INC
Entity Type:Organization
Organization Name:NORTHEAST MISSOURI HEALTH COUNCIL INC
Other - Org Name:NORTHEAST MISSOURI PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-627-5757
Mailing Address - Street 1:314 E MCPHERSON ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3557
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:600 W. JEFFERSON
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-2819
Practice Address - Country:US
Practice Address - Phone:660-627-2229
Practice Address - Fax:660-627-2233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005037590208000000X
MO2006022612208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503351801Medicaid
MO503351801Medicaid
000011740Medicare PIN