Provider Demographics
NPI:1235275249
Name:NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Entity Type:Organization
Organization Name:NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Other - Org Name:NORTHEAST MISSOURI FAMILY HEALTH 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:RR 1 BOX 55
Practice Address - Street 2:SIGLER AVENUE
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-9726
Practice Address - Country:US
Practice Address - Phone:660-465-7037
Practice Address - Fax:660-465-7350
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-29
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001023603207Q00000X
MO076376363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503351827Medicaid
MO503351827Medicaid
000012165Medicare PIN