Healthcare Provider Details

I. General information

NPI: 1871549345
Provider Name (Legal Business Name): JEFFERSON CITY MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 W STADIUM BLVD SUITE L400B
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 Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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