Basic Information
| Provider Information | |||||||||
| NPI: | 1811166465 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMY R LOCKHERT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | THE KENNETT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638572041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738881137 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 105 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638572041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738881137 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 09/03/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOCKHERT | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5738881137 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
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 | 595423609 | 05 | MO | MEDICAID |