Provider Demographics
NPI:1982788196
Name:SOUTHEAST HOSPITAL
Entity Type:Organization
Organization Name:SOUTHEAST HOSPITAL
Other - Org Name:MERCY HOSPICE
Other - Org Type:Doing Business As
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:573-335-6208
Mailing Address - Fax:573-334-8754
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:573-335-6208
Practice Address - Fax:573-334-8754
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-24
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO037-9HO251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
261537Medicare Oscar/Certification