Provider Demographics
NPI:1891201331
Name:PIKE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PIKE COUNTY MEMORIAL HOSPITAL
Other - Org Name:PCMH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-754-5531
Mailing Address - Street 1:2305 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:LOUISIANA
Mailing Address - State:MO
Mailing Address - Zip Code:63353-2559
Mailing Address - Country:US
Mailing Address - Phone:573-754-5531
Mailing Address - Fax:
Practice Address - Street 1:425 N GALLOWAY RD
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:MO
Practice Address - Zip Code:63382-1259
Practice Address - Country:US
Practice Address - Phone:573-594-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty