Basic Information
| Provider Information | |||||||||
| NPI: | 1891201331 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIKE COUNTY MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | PCMH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2305 GEORGIA ST | ||||||||
| Address2: | |||||||||
| City: | LOUISIANA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633532559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737545531 | ||||||||
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| Practice Location | |||||||||
| Address1: | 425 N GALLOWAY RD | ||||||||
| Address2: | |||||||||
| City: | VANDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633821259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735942111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 12/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | SELLE | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5737545531 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.