Provider Demographics
NPI:1609059815
Name:NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Entity Type:Organization
Organization Name:NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Other - Org Name:KIRKSVILLE VETERANS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-627-5757
Mailing Address - Street 1:1416 CROWN DRIVE
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-0000
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:1510 CROWN DRIVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4002
Practice Address - Country:US
Practice Address - Phone:660-627-8387
Practice Address - Fax:660-627-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2203032101101YP2500X
MOR5C53207Q00000X
MO104748363L00000X
MO2010018560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000011740Medicare PIN