Healthcare Provider Details

I. General information

NPI: 1316178189
Provider Name (Legal Business Name): JOSEPH ALBERT AMAVISCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL DR
HANNIBAL MO
63401-6877
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-5250
  • Fax: 573-221-3706
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-277-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD156341
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2025012600
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: