Basic Information
| Provider Information | |||||||||
| NPI: | 1033294889 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCUNE-BROOKS HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MCCUNE-BROOKS REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3125 DR RUSSELL SMITH WAY | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648367402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4163588121 | ||||||||
| FaxNumber: | 4172377240 | ||||||||
| Practice Location | |||||||||
| Address1: | 3125 DR RUSSELL SMITH WAY | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648367402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4163588121 | ||||||||
| FaxNumber: | 4172377240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 04/05/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COPELAND | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4173588121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 23-48 | MO | Y | Hospital Units | Psychiatric Unit |
No ID Information.