Basic Information
Provider Information | |||||||||
NPI: | 1093012890 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PCRMC MEDICAL GROUP INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 579 | ||||||||
Address2: |   | ||||||||
City: | ROLLA | ||||||||
State: | MO | ||||||||
PostalCode: | 654020579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5734583425 | ||||||||
FaxNumber: | 5734262282 | ||||||||
Practice Location | |||||||||
Address1: | 1050 W 10TH ST | ||||||||
Address2: | STE 420 | ||||||||
City: | ROLLA | ||||||||
State: | MO | ||||||||
PostalCode: | 654012905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5734583425 | ||||||||
FaxNumber: | 5734262282 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2011 | ||||||||
LastUpdateDate: | 02/15/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WAGHER | ||||||||
AuthorizedOfficialFirstName: | HAL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CORPORATE COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5734587615 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MODOR4D88 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   | 213E00000X | 2009011768 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
No ID Information.