Provider Demographics
NPI:1437251634
Name:PEMISCOT COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PEMISCOT COUNTY MEMORIAL HOSPITAL
Other - Org Name:DOCTORS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE-WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-359-3612
Mailing Address - Street 1:946 E REED ST
Mailing Address - Street 2:P O BOX 489
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-1243
Mailing Address - Country:US
Mailing Address - Phone:573-359-3612
Mailing Address - Fax:573-359-3601
Practice Address - Street 1:106 WEST 12TH ST
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830
Practice Address - Country:US
Practice Address - Phone:573-359-1782
Practice Address - Fax:573-333-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO594778409Medicaid
MO594778409Medicaid