Provider Demographics
NPI:1932372646
Name:PEMISCOT COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PEMISCOT COUNTY MEMORIAL HOSPITAL
Other - Org Name:BOOTHEEL PRIMARY CARE NEW MADRID
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-359-3659
Mailing Address - Street 1:PO BOX 442
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-0442
Mailing Address - Country:US
Mailing Address - Phone:573-359-3659
Mailing Address - Fax:573-359-3608
Practice Address - Street 1:555 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869
Practice Address - Country:US
Practice Address - Phone:573-748-3107
Practice Address - Fax:573-748-3112
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEMISCOT COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-03
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO597723402Medicaid
MO268627Medicare Oscar/Certification