1114242914 NPI number — PHYSICIANS MEDICAL CLINIC, LLC

Table of content: (NPI 1114242914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114242914 NPI number — PHYSICIANS MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS MEDICAL CLINIC, 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:
1114242914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 MCCLELLAND BLVD
Provider Second Line Business Mailing Address:
BLDG. B STE. 216
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64804-1623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-627-9600
Provider Business Mailing Address Fax Number:
417-627-9632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 MCCLELLAND BLVD
Provider Second Line Business Practice Location Address:
BLDG. B STE. 216
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-1623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-627-9600
Provider Business Practice Location Address Fax Number:
417-627-9632
Provider Enumeration Date:
04/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ROSS
Authorized Official First Name:
BECKY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
417-627-9600

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  110186 , 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)





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