Provider Demographics
NPI:1639351935
Name:SOUTHEAST HOSPITAL
Entity Type:Organization
Organization Name:SOUTHEAST HOSPITAL
Other - Org Name:SOUTHEAST MISSOURI HOSPITAL ASSOCIATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:BATEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-651-5500
Mailing Address - Street 1:1701 LACEY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5230
Mailing Address - Country:US
Mailing Address - Phone:573-651-5500
Mailing Address - Fax:
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-651-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO80-49273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
26S110Medicare Oscar/Certification