Healthcare Provider Details

I. General information

NPI: 1467518464
Provider Name (Legal Business Name): EASTERN MISSOURI GENERAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 NO STATE STREET
DESLOGE MO
63601-3052
US

IV. Provider business mailing address

322 NO STATE STREET
DESLOGE MO
63601-3052
US

V. Phone/Fax

Practice location:
  • Phone: 573-431-4510
  • Fax: 573-431-4790
Mailing address:
  • Phone: 573-431-4510
  • Fax: 573-431-4790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10179
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9A44
License Number StateMO

VIII. Authorized Official

Name: MR. RIOHARD MARTIN SECOR JR.
Title or Position: PRESIDENT PHYSICIAN
Credential: DO
Phone: 573-431-4510