Provider Demographics
NPI:1962548974
Name:NORTHEAST MISSOURI HEALTH COUNCIL INC
Entity type:Organization
Organization Name:NORTHEAST MISSOURI HEALTH COUNCIL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-627-5757
Mailing Address - Street 1:1416 CROWN DRIVE
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2548
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:1506 CROWN DRIVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-627-4493
Practice Address - Fax:660-627-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0022411041C0700X
MO20060056221041C0700X
MO20050374241041C0700X
MOR5E64207Q00000X
MOR5N07207Q00000X
MO111208207Q00000X
MO261QF0400X
MO096968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503351843Medicaid
MO005011740Medicare PIN
MO117400005Medicare PIN
MO117400011Medicare PIN
MO261848Medicare Oscar/Certification
MO117400003Medicare PIN
MO117400006Medicare PIN
MO000011740Medicare PIN