Provider Demographics
NPI:1285690644
Name:ADVANCED HEALTH CARE MANAGEMENT SERVICES, LLC
Entity Type:Organization
Organization Name:ADVANCED HEALTH CARE MANAGEMENT SERVICES, LLC
Other - Org Name:ADVANCED HEALTHCARE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-778-0020
Mailing Address - Street 1:PO BOX 989
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0989
Mailing Address - Country:US
Mailing Address - Phone:573-778-0020
Mailing Address - Fax:573-776-7548
Practice Address - Street 1:100 HIGHWAY 21 N
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638-9409
Practice Address - Country:US
Practice Address - Phone:573-663-2511
Practice Address - Fax:573-663-2815
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED HEALTH CARE MANAGEMENT SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-25
Last Update Date:2013-07-30
Deactivation Date:2013-02-06
Deactivation Code:
Reactivation Date:2013-07-30
Provider Licenses
StateLicense IDTaxonomies
MO459-5282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010323707Medicaid
261304Medicare Oscar/Certification
MO010323707Medicaid
MO000013495Medicare PIN