Provider Demographics
NPI:1699873372
Name:PEMISCOT COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:PEMISCOT COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-359-3612
Mailing Address - Street 1:314 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-1616
Mailing Address - Country:US
Mailing Address - Phone:573-379-3777
Mailing Address - Fax:573-379-9331
Practice Address - Street 1:314 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1616
Practice Address - Country:US
Practice Address - Phone:573-379-3777
Practice Address - Fax:573-379-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO596948109Medicaid
MO263421Medicare Oscar/Certification