Healthcare Provider Details

I. General information

NPI: 1083897862
Provider Name (Legal Business Name): JEFFERSON CITY MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 E BUCHANAN ST
CALIFORNIA MO
65018-1910
US

IV. Provider business mailing address

PO BOX 104240
JEFFERSON CITY MO
65110-4240
US

V. Phone/Fax

Practice location:
  • Phone: 573-796-3600
  • Fax: 573-796-7251
Mailing address:
  • Phone: 573-635-5246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36976
License Number StateMO

VIII. Authorized Official

Name: DR. JEFFREY LEE PATRICK
Title or Position: PRESIDENT
Credential: MD
Phone: 573-635-5264