Basic Information
| Provider Information | |||||||||
| NPI: | 1669809661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LINCOLN COUNTY MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | LCMC CARDIOLOGY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 E CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633791513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365288551 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 E CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633791513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365288551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2013 | ||||||||
| LastUpdateDate: | 10/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | THORN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6365283329 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LINCOLN COUNTY MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.