Provider Demographics
NPI:1649697566
Name:SOUTHEAST MISSOURI HEALTH NETWORK
Entity type:Organization
Organization Name:SOUTHEAST MISSOURI HEALTH NETWORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
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:CARUTHERSVILLE MEDICAL CENTER
Practice Address - Street 2:109 EAST 5TH STREET
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1417
Practice Address - Country:US
Practice Address - Phone:573-359-9803
Practice Address - Fax:573-359-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1649697566Medicaid
MO1649697566Medicaid