Healthcare Provider Details

I. General information

NPI: 1083661615
Provider Name (Legal Business Name): JEFFERSON CITY MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 E MAIN ST
LINN MO
65051-2503
US

IV. Provider business mailing address

1306 E MAIN ST
LINN MO
65051-2503
US

V. Phone/Fax

Practice location:
  • Phone: 573-897-2202
  • Fax: 573-897-3157
Mailing address:
  • Phone: 573-897-2202
  • Fax: 573-897-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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