Healthcare Provider Details

I. General information

NPI: 1467518423
Provider Name (Legal Business Name): JEFFERSON CITY MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 W STADIUM BLVD SUITE 1140
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: 573-556-7717
  • Fax: 573-556-1717
Mailing address:
  • Phone: 573-556-7717
  • Fax: 573-556-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL CRAIGHEAD
Title or Position: COO
Credential: M.D.
Phone: 573-556-7776