Provider Demographics
NPI:1417937160
Name:MCCUNE BROOKS HOSPITAL
Entity Type:Organization
Organization Name:MCCUNE BROOKS HOSPITAL
Other - Org Name:MCCUNE BROOKS HOME HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:Y
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:417-358-8121
Mailing Address - Street 1:3125 DR RUSSELL SMITH WAY
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-7402
Mailing Address - Country:US
Mailing Address - Phone:417-358-8121
Mailing Address - Fax:
Practice Address - Street 1:3125 DR RUSSELL SMITH WAY
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-7402
Practice Address - Country:US
Practice Address - Phone:417-358-8121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCCUNE BROOKS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-19
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO182.21251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO580670909Medicaid
MO102OtherBLUE CROSS BLUE SHIELD IN
MO580670909Medicaid
MO1417937160Medicare Oscar/Certification