Provider Demographics
NPI:1902820012
Name:LINCOLN COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:LINCOLN COUNTY MEMORIAL HOSPITAL
Other - Org Name:DOCTORS PROFESSIONAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-528-3326
Mailing Address - Street 1:1165 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1520
Mailing Address - Country:US
Mailing Address - Phone:636-528-7722
Mailing Address - Fax:636-528-7744
Practice Address - Street 1:1165 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1520
Practice Address - Country:US
Practice Address - Phone:636-528-7722
Practice Address - Fax:636-528-7744
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LINCOLN COUNTY MEMORIAL HOSPITAL DBA LINCOLN COUNTY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242201705Medicaid
MO268687Medicare Oscar/Certification
MO242201705Medicaid