Provider Demographics
NPI:1619065828
Name:SULLIVAN COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SULLIVAN COUNTY MEMORIAL HOSPITAL
Other - Org Name:SULLIVAN COUNTY MEMORIAL HOSPITAL MILAN FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-265-4212
Mailing Address - Street 1:630 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MO
Mailing Address - Zip Code:63556-1076
Mailing Address - Country:US
Mailing Address - Phone:660-265-4212
Mailing Address - Fax:660-265-4898
Practice Address - Street 1:210 N MARKET ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MO
Practice Address - Zip Code:63556-1316
Practice Address - Country:US
Practice Address - Phone:660-265-4456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SULLIVAN COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO591720800Medicaid
MO501720809Medicaid
MO501720809Medicaid
MO000012067Medicare ID - Type UnspecifiedNON RHC MEDICARE