Basic Information
| Provider Information | |||||||||
| NPI: | 1659366417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN COUNTY HEALTH DEPARTMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 HEALTH DEPARTMENT DR | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633794551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365286117 | ||||||||
| FaxNumber: | 6365288629 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 HEALTH DEPARTMENT DR | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633794551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365286117 | ||||||||
| FaxNumber: | 6365288629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | SIEFERT | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6365286117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 053723 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 511575201 | 05 | MO | MEDICAID |