1306017769 NPI number — MT. AUBURN MEDICAL GROUP, LLC

Table of content: (NPI 1306017769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306017769 NPI number — MT. AUBURN MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT. AUBURN MEDICAL GROUP, 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:
6
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:
1306017769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 S MOUNT AUBURN RD
Provider Second Line Business Mailing Address:
SUITE 342
Provider Business Mailing Address City Name:
CAPE GIRARDEAU
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63703-4911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-335-2212
Provider Business Mailing Address Fax Number:
573-339-5946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 S MOUNT AUBURN RD
Provider Second Line Business Practice Location Address:
SUITE 342
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-335-2212
Provider Business Practice Location Address Fax Number:
573-339-5946
Provider Enumeration Date:
03/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BIESER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
573-335-2212

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  104929 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 1004971 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 116768 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1174611966 . This is a "JEFFREY W. CHILDERS, MD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1386732196 . This is a "ROBERT D. BIESER, DO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1467542571 . This is a "PHILIP E. TIPPEN, MD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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