Provider Demographics
NPI:1912926429
Name:HANNIBAL REGIONAL HEALTHCARE SYSTEM, INC
Entity Type:Organization
Organization Name:HANNIBAL REGIONAL HEALTHCARE SYSTEM, INC
Other - Org Name:MONROE CITY FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-248-1300
Mailing Address - Street 1:6000 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6887
Mailing Address - Country:US
Mailing Address - Phone:573-248-1300
Mailing Address - Fax:
Practice Address - Street 1:821 US HIGHWAY 24 AND 36 E
Practice Address - Street 2:
Practice Address - City:MONROE CITY
Practice Address - State:MO
Practice Address - Zip Code:63456-1470
Practice Address - Country:US
Practice Address - Phone:573-735-2506
Practice Address - Fax:573-735-1083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO598962108Medicaid
MO598962108Medicaid