Provider Demographics
NPI:1699073122
Name:SOUTHEAST MISSOURI HOSPITAL PHYSICIANS LLC
Entity type:Organization
Organization Name:SOUTHEAST MISSOURI HOSPITAL PHYSICIANS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-331-6028
Mailing Address - Street 1:817 S MOUNT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6383
Mailing Address - Country:US
Mailing Address - Phone:573-519-4500
Mailing Address - Fax:
Practice Address - Street 1:817 S MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6383
Practice Address - Country:US
Practice Address - Phone:573-519-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST MISSOURI HOSPITAL PHYSICIANS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-08
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
268657Medicare Oscar/Certification