NPIMap

Organization Active NPI

Southeast Missouri Health Network

Doing business as benton medical center

  • Federally Qualified Health Center (FQHC)
  • Benton, MO
National Provider Identifier
1528348778
Registry record updated Aug 6, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTHEAST MISSOURI HEALTH NETWORK
Doing business as
benton medical center
Practice address
6724 Highway 77 E
Benton, MO 63736
Phone
(573) 545-4191
Fax
(573) 545-4425
NPI assigned
Aug 19, 2011
Last updated
Aug 6, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 6, 2014

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

Authorized official

Name
Chris Jones
Title
Chief Executive Officer
Phone
(573) 748-2404

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
General Practice Dentistry 1223G0001X NU

Addresses

Primary practice location

6724 Highway 77 E
Benton, MO 63736

Mailing address

420 Semo Dr
New Madrid, MO 63869-1734
Phone (573) 748-2404

Other identifiers 1

IdentifierTypeStateIssuer
1497035661MedicaidMO

Other names 1

  • benton medical center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050412000011 MO Part B Supplier - Clinic/Group Practice 6507818044 Receives reassigned benefits from 20 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Caruthersville, MO; Sikeston, MO; New Madrid, MO; Kennett, MO; Bernie, MO; Benton, MO

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
26D2032520Benton Medical Center6724 Highway 77, Benton, MO 63736Certificate of waiverNov 8, 2027

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1313712000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1407283200000",
    "number": "1528348778",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 SEMO DR",
            "city": "NEW MADRID",
            "state": "MO",
            "postal_code": "638691734",
            "telephone_number": "573-748-2404",
            "fax_number": "573-748-8929"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6724 HIGHWAY 77 E",
            "city": "BENTON",
            "state": "MO",
            "postal_code": "63736",
            "telephone_number": "573-545-4191",
            "fax_number": "573-545-4425"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST MISSOURI HEALTH NETWORK",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-08-19",
        "last_updated": "2014-08-06",
        "status": "A",
        "authorized_official_last_name": "JONES",
        "authorized_official_first_name": "CHRIS",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "573-748-2404"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1497035661",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "benton medical center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Benton, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 6, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.