Provider Demographics
NPI:1558311522
Name:SOUTHEAST MISSOURI HOSPITAL PHYSICIANS, LLC
Entity type:Organization
Organization Name:SOUTHEAST MISSOURI HOSPITAL PHYSICIANS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-331-6028
Mailing Address - Street 1:1701 LACEY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5230
Mailing Address - Country:US
Mailing Address - Phone:573-331-6880
Mailing Address - Fax:573-331-6887
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-331-6880
Practice Address - Fax:573-331-6887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505394007Medicaid
MO505394007Medicaid