Healthcare Provider Details

I. General information

NPI: 1073268215
Provider Name (Legal Business Name): VMD PRIMARY PROVIDERS EAST MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S CLARK ST STE 900
CHICAGO IL
60603-4043
US

IV. Provider business mailing address

4650 WESTWAY PARK BLVD
HOUSTON TX
77041-2007
US

V. Phone/Fax

Practice location:
  • Phone: 888-975-1055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA RAGER
Title or Position: DIRECTOR REVENUE CYCLE
Credential:
Phone: 844-969-0686