| Details | Last Recertification Date | Update | Recertification | 2/6/2024 12:21:56 PM | 2/24/2025 9:13:42 AM | 2/24/2025 9:13 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Matthews, Mallory
Director of Clinical Operations
Southeast Missouri Health Network
5733132500 | Matthews, Mallory
Chief Clinical Officer
Southeast Missouri Health Network
5733132500 | 7/15/2024 3:26 PM |
| Details | Last Recertification Date | Update | Recertification | 2/22/2023 10:50:55 AM | 2/6/2024 12:21:56 PM | 2/6/2024 12:21 PM |
| Contacts | Primary Contact | Update | Group Change Request | Girffin, Aaron
Policy Director
Southeast Missouri Health Network
5733132501 | Matthews, Mallory
Director of Clinical Operations
Southeast Missouri Health Network
5733132500 | 2/22/2023 11:17 AM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2022 10:59:54 AM | 2/22/2023 10:50:55 AM | 2/22/2023 10:50 AM |
| Details | Last Recertification Date | Update | Recertification | 2/23/2021 5:52:56 PM | 2/9/2022 10:59:54 AM | 2/9/2022 10:59 AM |
| Details | Last Recertification Date | Update | Recertification | 2/19/2020 7:45:30 AM | 2/23/2021 5:52:56 PM | 2/23/2021 5:52 PM |
| Addresses | Billing Address | Insert | Recertification | | SEMO Health Network
6738 St. Hwy 77
Benton, MO 63736 | 2/19/2020 7:45 AM |
| Addresses | Main Address | Update | Recertification |
223 South Third Street
Hayti, MO 63851-1617 |
109 E. 5th St.
Caruthersville, MO 63830 | 2/19/2020 7:45 AM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2019 9:26:43 AM | 2/19/2020 7:45:30 AM | 2/19/2020 7:45 AM |
| Details | Is Authorizing Official EHB Data | Update | Recertification | False | | 2/19/2020 7:45 AM |
| Details | Entity Subname | Update | Recertification | Hayti Family Medical and Dental Clinic | Caruthersville Medical and Dental Center | 2/19/2020 7:45 AM |
| Details | Last Recertification Date | Update | Recertification | 2/26/2018 6:17:04 PM | 1/31/2019 9:26:43 AM | 1/31/2019 9:26 AM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2017 12:00:00 AM | 2/26/2018 6:17:04 PM | 2/26/2018 6:17 PM |
| Contacts | Authorizing Official | Update | | JONES, CHRIS
CEO
5733132501 | JONES, CHRIS
CEO
SEMO Health Network
5733132501 | 2/26/2018 6:12 PM |
| Contacts | Signed By | Update | | JONES, CHRIS
CEO
5733132501 | JONES, CHRIS
CEO
SEMO Health Network
5733132501 | 2/26/2018 6:12 PM |
| Contacts | Primary Contact | Update | | Girffin, Aaron
Policy Director
5733132501 | Girffin, Aaron
Policy Director
Southeast Missouri Health Network
5733132501 | 1/8/2018 10:53 AM |
| Contacts | Authorizing Official | Insert | | | JONES, CHRIS
CEO
5733132501 | 2/8/2017 3:23 PM |
| Contacts | Signed By | Insert | | | JONES, CHRIS
CEO
5733132501 | 2/8/2017 3:23 PM |
| Addresses | Main Address | Insert | | |
223 South Third Street
Hayti, MO 63851-1617 | 2/1/2017 10:09 AM |
| Contacts | Primary Contact | Insert | | | Girffin, Aaron
Policy Director
5733132501 | 2/1/2017 10:09 AM |
| Details | Last Recertification Date | Update | | 2/16/2016 12:00:00 AM | 2/1/2017 12:00:00 AM | 2/1/2017 10:09 AM |
| Details | Last Recertification Date | Update | | | 2/16/2016 12:00:00 AM | 2/16/2016 12:25 PM |
| Dates | Participating Approval Date | Update | | | 1/28/2015 12:00:00 AM | 1/28/2015 5:10 PM |
| Details | State | Update | | Pending | Active | 1/28/2015 5:10 PM |
| Dates | Start Date | Update | | | 4/1/2015 12:00:00 AM | 1/28/2015 5:10 PM |
| Details | 340B ID | Update | | ONLINE_REG_49279 | CH07137R | 1/20/2015 3:27 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_49279 | 1/14/2015 3:11 PM |
| Details | Last Recertification Date | Insert | | | | 1/14/2015 3:11 PM |
| Details | Grant Number | Insert | | | H80CS00557 | 1/14/2015 3:11 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 1/14/2015 3:11 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 1/14/2015 3:11 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/14/2015 3:11 PM |
| Details | Medicare Provider Number | Insert | | | | 1/14/2015 3:11 PM |
| Details | Entity Name | Insert | | | SOUTHEAST MISSOURI HEALTH NETWORK | 1/14/2015 3:11 PM |
| Details | Program Code | Insert | | | CH | 1/14/2015 3:11 PM |
| Details | Entity Subname | Insert | | | Hayti Family Medical and Dental Clinic | 1/14/2015 3:11 PM |
| Dates | Participating Approval Date | Insert | | | | 1/14/2015 3:11 PM |
| Details | State | Insert | | | Pending | 1/14/2015 3:11 PM |
| Dates | Registration Date | Insert | | | 1/14/2015 12:00:00 AM | 1/14/2015 3:11 PM |
| Dates | Signed By Date | Insert | | | 1/14/2015 12:00:00 AM | 1/14/2015 3:11 PM |
| Dates | Start Date | Insert | | | | 1/14/2015 3:11 PM |
| Terminations | Termination Comments | Insert | | | | 1/14/2015 3:11 PM |
| Terminations | Termination Date | Insert | | | | 1/14/2015 3:11 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/14/2015 3:11 PM |
| Terminations | Termination Reason | Insert | | | | 1/14/2015 3:11 PM |