Basic Information
| Provider Information | |||||||||
| NPI: | 1104804699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KNEIBERT CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 220 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736862411 | ||||||||
| FaxNumber: | 5736868452 | ||||||||
| Practice Location | |||||||||
| Address1: | 686 LESTER ST | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736862411 | ||||||||
| FaxNumber: | 5736868452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTIAN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5737787210 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 107927002 | 05 | AR | MEDICAID | 500295407 | 05 | MO | MEDICAID |