1033481163 NPI number — J K ESSMYER MEDICAL SERVICES LLC

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 1033481163 NPI number — J K ESSMYER MEDICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J K ESSMYER MEDICAL SERVICES LLC
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:
Provider Other Organization Name Type Code:
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:
1033481163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
933 COUNTY ROAD 389
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITEWATER
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63785-6039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-833-6630
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MT AUBURN RD
Provider Second Line Business Practice Location Address:
AUBURN SURGERY CENTER, INC
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-332-7881
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ESSMYER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
SR MEMBER
Authorized Official Telephone Number:
573-270-5092

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  31286 , 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: 200111615 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".