MEDICARE: PHYSICIAN SERVICES OF MISSOURI LLC

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
1	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHC059	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1164792032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN SERVICES OF MISSOURI LLC

Provider Business Mailing Address
First Line	:	989 GOVERNORS LN
Second Line	:	SUITE 160
City	:	LEXINGTON
State	:	KY
Zip	:	40513-1173
Country	:	US
Telephone Number	:	859-514-5547
Fax Number	:	859-422-4907

Provider Business Practice Location Address
First Line	:	1611 S BALTIMORE ST
Second Line	:
City	:	KIRKSVILLE
State	:	MO
Zip	:	63501-4536
Country	:	US
Telephone Number	:	859-514-5547
Fax Number	:	859-422-4907

Authorized Official
Title or Position	:	MANAGER
Name	:	CASEY DELOACH
Credential	:
Telephone Number	:	888-829-8550

Provider Enumeration Date	:	01/09/2012
Last Update Date	:	01/09/2012

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