Provider Demographics
NPI:1336491448
Name:KIRKSVILLE MISSOURI HOSPITAL COMPANY LLC
Entity Type:Organization
Organization Name:KIRKSVILLE MISSOURI HOSPITAL COMPANY LLC
Other - Org Name:NORTHEAST REGIONAL MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEOPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7585
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:615-465-3007
Practice Address - Street 1:1607 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4536
Practice Address - Country:US
Practice Address - Phone:660-627-3363
Practice Address - Fax:660-627-3367
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIRKSVILLE MISSOURI HOSPITAL COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-12
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X, 207R00000X, 207RC0000X
207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty