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NPI Code Detail

MEDICARE: DR. RODERIC CLAYTON CRIST MD

MEDICARE: DR. RODERIC CLAYTON CRIST MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianR2H52MO

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2080192016OTHERMORAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1820571426OTHERMOTRICARE

General Provider Information

NPI Number : 1033180120
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. RODERIC CLAYTON CRIST MD
Provider Business Mailing Address
First Line : 3095 LEXINGTON AVE
Second Line : SUITE 200
City : CAPE GIRARDEAU
State : MO
Zip : 63701-2602
Country : US
Telephone Number : 573-339-0004
Fax Number :
Provider Business Practice Location Address
First Line : 3095 LEXINGTON AVE
Second Line : SUITE 200
City : CAPE GIRARDEAU
State : MO
Zip : 63701-2602
Country : US
Telephone Number : 573-339-0004
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/28/2006
Last Update Date : 08/11/2011

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