Provider Demographics
NPI:1093849481
Name:GRUNDY COUNTY HEALTH DEPT
Entity Type:Organization
Organization Name:GRUNDY COUNTY HEALTH DEPT
Other - Org Name:GRUNDY COUNTY HEALTH DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-359-4196
Mailing Address - Street 1:1716 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-1584
Mailing Address - Country:US
Mailing Address - Phone:660-359-4196
Mailing Address - Fax:660-359-5470
Practice Address - Street 1:1716 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-1584
Practice Address - Country:US
Practice Address - Phone:660-359-4196
Practice Address - Fax:660-359-5470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14277883251K00000X
251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO511844508Medicaid
MO9003951Medicare ID - Type UnspecifiedMEDICARE BILLING NUMBER
MO511844508Medicaid