Basic Information
| Provider Information | |||||||||
| NPI: | 1174757504 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HANNIBAL CLINIC OPERATIONS, L.L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HANNIBAL CLINIC @ CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | HANNIBAL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634016877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732215250 | ||||||||
| FaxNumber: | 5732313706 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E HIGHWAY 19 | ||||||||
| Address2: | |||||||||
| City: | CENTER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634361044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732673318 | ||||||||
| FaxNumber: | 5732673933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2009 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUKSTEIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5732313172 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500221007 | 05 | MO | MEDICAID |