Basic Information
| Provider Information | |||||||||
| NPI: | 1851682025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMMEDIATE CONVENIENT CARE-PERRYVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 N KINGSHIGHWAY ST | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637012122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733392000 | ||||||||
| FaxNumber: | 5733391876 | ||||||||
| Practice Location | |||||||||
| Address1: | 1508 EDGEMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | PERRYVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637751231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735177555 | ||||||||
| FaxNumber: | 5735177556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2011 | ||||||||
| LastUpdateDate: | 04/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | BALSANO | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 5733315228 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT FRANCIS HEALTHCARE SYSTEMS | ||||||||
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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 |
No ID Information.