Provider Demographics
NPI:1710108766
Name:SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type:Organization
Organization Name:SOUTHEAST MISSOURI HEALTH NETWORK
Other - Org Name:OTTO BEAN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-313-2500
Mailing Address - Street 1:6738 STATE HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-8238
Mailing Address - Country:US
Mailing Address - Phone:573-313-2500
Mailing Address - Fax:573-313-2505
Practice Address - Street 1:500 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2102
Practice Address - Country:US
Practice Address - Phone:573-717-1332
Practice Address - Fax:573-717-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500704036Medicaid
MO500704036Medicaid
MO261847Medicare Oscar/Certification