MEDICARE: MIDWEST HEALTH GROUP CONVENIENT CARE, 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	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1982057501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST HEALTH GROUP CONVENIENT CARE, LLC

Provider Business Mailing Address
First Line	:	55 NESBIT DR
Second Line	:
City	:	BONNE TERRE
State	:	MO
Zip	:	63628-1353
Country	:	US
Telephone Number	:	573-358-1700
Fax Number	:	573-358-1702

Provider Business Practice Location Address
First Line	:	550 MAPLE VALLEY DR
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1981
Country	:	US
Telephone Number	:	573-454-2466
Fax Number	:	573-454-2544

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. MARY ELIZABETH CHANDLER
Credential	:	FNP-C
Telephone Number	:	573-358-1700

Provider Enumeration Date	:	07/19/2016
Last Update Date	:	07/19/2016

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