Basic Information
| Provider Information | |||||||||
| NPI: | 1114235041 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PCRMC MEDICAL GROUP, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHELPS HEALTH MEDICAL GROUP VIENNA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 579 | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734262182 | ||||||||
| FaxNumber: | 5734265341 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 HIGHWAY 63 S | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655828101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734223636 | ||||||||
| FaxNumber: | 5734223434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2010 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5734587916 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PCRMC MEDICAL GROUP, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 2007024375 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 594328304 | 05 | MO | MEDICAID |