Mid-South Health Clinic LLC

Primary specialty

Rural Health Clinic/CenterTaxonomy code 261QR1300X

License

031640 Issued in MO

Legal business name

MID-SOUTH HEALTH CLINIC LLC

Practice address

3100 Warrior LN
Poplar Bluff, MO 63901-8686

Phone

(573) 785-0851

NPI assigned

Nov 16, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Joetta Martin

Title

Administrator

Phone

(573) 785-0851

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1132099200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1215648000000",
    "number": "1073595096",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "233 E CENTER DR",
            "city": "ALTON",
            "state": "IL",
            "postal_code": "620025931",
            "telephone_number": "618-465-7717",
            "fax_number": "618-465-7710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3100 WARRIOR LN",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639018686",
            "telephone_number": "573-785-0851"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MID-SOUTH HEALTH CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-16",
        "last_updated": "2008-07-10",
        "status": "A",
        "authorized_official_last_name": "MARTIN",
        "authorized_official_first_name": "JOETTA",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "573-785-0851"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MO",
            "license": "031640",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "598977007",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.