Basic Information
| Provider Information | |||||||||
| NPI: | 1699873372 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEMISCOT COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PORTAGEVILLE PRIMARY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 314 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORTAGEVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638731616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733793777 | ||||||||
| FaxNumber: | 5733799331 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORTAGEVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638731616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733793777 | ||||||||
| FaxNumber: | 5733799331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5733593612 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 596948109 | 05 | MO | MEDICAID |