1346513207 NPI number — JEFFERSON CITY MEDICAL GROUP, PC

Table of content: (NPI 1346513207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346513207 NPI number — JEFFERSON CITY MEDICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON CITY MEDICAL GROUP, PC
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:
1346513207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 104240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65110-4240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-635-5264
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5816 OSAGE BEACH PKWY STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSAGE BEACH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65065-3046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-348-3001
Provider Business Practice Location Address Fax Number:
573-348-5998
Provider Enumeration Date:
02/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PATRICK
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
573-635-5264

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  R8640 , 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)





Copyright © 2007-2025 www.npivalidator.com