Basic Information
| Provider Information | |||||||||
| NPI: | 1164615316 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIAN GROUPS LC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTRALIA FAMILY HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652015844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738156245 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1021 E HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652401183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736825580 | ||||||||
| FaxNumber: | 5736821539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANTER-KOESTER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3149967610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.