1114235041 NPI number — PCRMC MEDICAL GROUP, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114235041 NPI number — PCRMC MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PCRMC MEDICAL GROUP, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHELPS HEALTH MEDICAL GROUP VIENNA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114235041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 579
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLLA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-426-2182
Provider Business Mailing Address Fax Number:
573-426-5341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 HIGHWAY 63 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65582-8101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-422-3636
Provider Business Practice Location Address Fax Number:
573-422-3434
Provider Enumeration Date:
09/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
JANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
VP, CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
573-458-7916

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  2007024375 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 594328304 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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