Provider Demographics
NPI:1720209794
Name:SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type:Organization
Organization Name:SOUTHEAST MISSOURI HEALTH NETWORK
Other - Org Name:SOUTHEAST HEALTH ON WHEELS MOBILE VAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-748-2404
Mailing Address - Street 1:420 LINE ST
Mailing Address - Street 2:P.O. BOX 400
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-1734
Mailing Address - Country:US
Mailing Address - Phone:573-748-2404
Mailing Address - Fax:573-748-8929
Practice Address - Street 1:700 N DOUGLASS ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-1510
Practice Address - Country:US
Practice Address - Phone:573-748-7701
Practice Address - Fax:573-748-2554
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST MISSOURI HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-01
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500704028Medicaid
MO000010626OtherGROUP PTAN
MO261825Medicare Oscar/Certification