Provider Demographics
NPI:1124074430
Name:DREW COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:DREW COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-460-3599
Mailing Address - Street 1:400 EAST 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3620
Practice Address - Street 1:778 SCOGIN DRIVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5729
Practice Address - Country:US
Practice Address - Phone:870-367-2411
Practice Address - Fax:952-442-3620
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DREW COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159964002Medicaid
AR5F446OtherBLUE CROSS OF AR
AR5F446OtherBLUE CROSS OF AR