Provider Demographics
NPI:1124030424
Name:PIKE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PIKE COUNTY MEMORIAL HOSPITAL
Other - Org Name:PCMH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-754-5531
Mailing Address - Street 1:2305 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:LOUISIANA
Mailing Address - State:MO
Mailing Address - Zip Code:63353-2559
Mailing Address - Country:US
Mailing Address - Phone:573-754-4584
Mailing Address - Fax:573-754-5280
Practice Address - Street 1:1015 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-1974
Practice Address - Country:US
Practice Address - Phone:573-324-5300
Practice Address - Fax:573-324-6059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCK7206OtherRAILROAD MEDICARE PIN
MO502663305OtherMEDICARE/MEDICAID PROF CROSSOVER 1500
MO598209203Medicaid
MO263468Medicare Oscar/Certification
MO000012300Medicare PIN