Provider Demographics
NPI:1710093778
Name:PEMISCOT COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PEMISCOT COUNTY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-359-3612
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:946 EAST REED
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-0489
Mailing Address - Country:US
Mailing Address - Phone:573-359-1372
Mailing Address - Fax:573-359-3398
Practice Address - Street 1:946 E REED ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1243
Practice Address - Country:US
Practice Address - Phone:573-359-3612
Practice Address - Fax:573-359-3398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620988501Medicaid
MO0510270001Medicare ID - Type Unspecified