Provider Demographics
NPI:1407158678
Name:PERRY COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PERRY COUNTY MEMORIAL HOSPITAL
Other - Org Name:PERRY COUNTY MEMORIAL HOSPITAL AMBULANCE SERVICE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-547-2536
Mailing Address - Street 1:434 N WEST STREET
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775
Mailing Address - Country:US
Mailing Address - Phone:573-768-3203
Mailing Address - Fax:
Practice Address - Street 1:201 N. KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775
Practice Address - Country:US
Practice Address - Phone:573-768-3203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERRY COUNTY HEALTH SYSTEM DBA PERRY COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-22
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO157007OtherMISSOURI DHSS LICENCE