Basic Information
| Provider Information | |||||||||
| NPI: | 1689667750 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LINCOLN COUNTY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 E CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633791513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365288551 | ||||||||
| FaxNumber: | 6365285431 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633791513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365288551 | ||||||||
| FaxNumber: | 6365285431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THORN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6365283329 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 21-53 | MO | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | 2148 | MO | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | 21-54 | MO | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 010419802 | 05 | MO | MEDICAID |