Healthcare Provider Details

I. General information

NPI: 1235533498
Provider Name (Legal Business Name): JEFFERSON CITY MEDICAL GROUP-P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 S HIGHWAY 65 STE A
MARSHALL MO
65340-3735
US

IV. Provider business mailing address

PO BOX 104240
JEFFERSON CITY MO
65110-4240
US

V. Phone/Fax

Practice location:
  • Phone: 660-886-3364
  • Fax: 660-886-6044
Mailing address:
  • Phone: 573-635-5264
  • Fax: 573-556-5757

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY LEE PATRICK
Title or Position: PRESIDENT
Credential: MD
Phone: 573-635-5264