Basic Information
| Provider Information | |||||||||
| NPI: | 1073595096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-SOUTH HEALTH CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 233 E CENTER DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184657717 | ||||||||
| FaxNumber: | 6184657710 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 WARRIOR LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639018686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737850851 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | JOETTA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5737850851 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 031640 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 598977007 | 05 | MO | MEDICAID |