Healthcare Provider Details

I. General information

NPI: 1689614646
Provider Name (Legal Business Name): JEFFERSON CITY MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 W STADIUM BLVD FIRST FLOOR, SUITE 1300
JEFFERSON CITY MO
65109-6023
US

IV. Provider business mailing address

PO BOX 104240
JEFFERSON CITY MO
65110-4240
US

V. Phone/Fax

Practice location:
  • Phone: 573-556-5747
  • Fax: 573-636-9756
Mailing address:
  • Phone: 573-635-5264
  • Fax: 573-636-9756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500076906
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: DR. JEFFREY LEE PATRICK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 573-635-5264