Basic Information
| Provider Information | |||||||||
| NPI: | 1629052063 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL SPECIALISTS OF SOUTHEAST MISSOURI, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191850 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631197850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148218055 | ||||||||
| FaxNumber: | 3148211833 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 SAINT FRANCIS DR | ||||||||
| Address2: | ATTN INFECTIOUS DISEASE DEPT | ||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733313000 | ||||||||
| FaxNumber: | 5733313000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | LAVALLE | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5733344822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 100253 | MO | Y | Hospitals | General Acute Care Hospital |
No ID Information.