Provider Demographics
NPI:1376536953
Name:GREAT MINES HEALTH CENTER
Entity Type:Organization
Organization Name:GREAT MINES HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-438-9355
Mailing Address - Street 1:#1 SOUTHTOWNE DRIVE
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1455
Mailing Address - Country:US
Mailing Address - Phone:573-438-9355
Mailing Address - Fax:573-438-7892
Practice Address - Street 1:#1 SOUTHTOWNE DRIVE
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1455
Practice Address - Country:US
Practice Address - Phone:573-438-9355
Practice Address - Fax:573-438-7892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26-1878OtherUNITED GOVERNMENT SERVICE
MO509215109Medicaid
MO509215109Medicaid