Healthcare Provider Details

I. General information

NPI: 1740396035
Provider Name (Legal Business Name): MID MISSOURI MEDICAL CONSULTANTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MADISON ST
JEFFERSON CITY MO
65101-2753
US

IV. Provider business mailing address

1111 MADISON ST
JEFFERSON CITY MO
65101-2753
US

V. Phone/Fax

Practice location:
  • Phone: 573-635-7651
  • Fax: 573-659-4515
Mailing address:
  • Phone: 573-635-7651
  • Fax: 573-659-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR4N29
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberR8638
License Number StateMO

VIII. Authorized Official

Name: NANCY WADLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-635-7651