Basic Information
| Provider Information | |||||||||
| NPI: | 1598718355 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNAL MEDICINE ASSOCIATES OF SOUTHEAST MISSOURI LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHYSICIANS PARK PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 225 PHYSICIANS PARK | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737275500 | ||||||||
| FaxNumber: | 5737780581 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 PHYSICIANS PARK | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737275500 | ||||||||
| FaxNumber: | 5737780581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 11/14/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CALDWELL | ||||||||
| AuthorizedOfficialFirstName: | F. | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5737275500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 595183401 | 05 | MO | MEDICAID |