Healthcare Provider Details

I. General information

NPI: 1164615316
Provider Name (Legal Business Name): PHYSICIAN GROUPS LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E HIGHWAY 22
CENTRALIA MO
65240-1183
US

IV. Provider business mailing address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

V. Phone/Fax

Practice location:
  • Phone: 573-682-5580
  • Fax: 573-682-1539
Mailing address:
  • Phone: 573-815-6245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAREN CANTER-KOESTER
Title or Position: VICE PRESIDENT/AUTHORIZED OFFICIAL
Credential:
Phone: 314-996-7610