Basic Information
| Provider Information | |||||||||
| NPI: | 1487829222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARUTHERSVILLE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 881 | ||||||||
| Address2: | |||||||||
| City: | CARUTHERSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638300881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5793330033 | ||||||||
| FaxNumber: | 5733332522 | ||||||||
| Practice Location | |||||||||
| Address1: | 412 WARD AVE | ||||||||
| Address2: | |||||||||
| City: | CARUTHERSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638301451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5793330033 | ||||||||
| FaxNumber: | 5733332522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2008 | ||||||||
| LastUpdateDate: | 04/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEDBETTER | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5736514488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 507402907 | 05 | MO | MEDICAID |