Healthcare Provider Details

I. General information

NPI: 1710400221
Provider Name (Legal Business Name): JEFFERSON CITY MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 03/29/2019
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: 573-556-5771
  • Fax: 573-636-9756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELISSA G ASTIN
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 573-556-7774