Healthcare Provider Details

I. General information

NPI: 1124679774
Provider Name (Legal Business Name): MCPHERSON MEDICAL & DIAGNOSTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 TEACO RD STE A
KENNETT MO
63857-3268
US

IV. Provider business mailing address

PO BOX 12545
BELFAST ME
04915-4016
US

V. Phone/Fax

Practice location:
  • Phone: 573-717-1072
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMELIA DORIS LEDBETTER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 573-335-4715