Basic Information
Provider Information
NPI: 1710283213
EntityType: 2
ReplacementNPI:  
OrganizationName: LINCOLN COUNTY MEMORIAL HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: ELSBERRY FAMILY HEALTH
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 106 BROADWAY ST
Address2: SUITE 3C
City: ELSBERRY
State: MO
PostalCode: 633431345
CountryCode: US
TelephoneNumber: 5738989100
FaxNumber:  
Practice Location
Address1: 106 BROADWAY ST
Address2: SUITE 3C
City: ELSBERRY
State: MO
PostalCode: 633431345
CountryCode: US
TelephoneNumber: 5738989100
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/31/2011
LastUpdateDate: 03/06/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: THORN
AuthorizedOfficialFirstName: MARK
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CHIEF FINANCIAL OFFICER
AuthorizedOfficialTelephone: 6365283329
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QR1300X  Y Ambulatory Health Care FacilitiesClinic/CenterRural Health

No ID Information.


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