Healthcare Provider Details

I. General information

NPI: 1437668746
Provider Name (Legal Business Name): JEFFERSON CITY MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 03/29/2019
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: 573-556-5771
  • Fax: 573-636-9756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELISSA G ASTIN
Title or Position: VP OF OPERATIONS
Credential:
Phone: 573-556-7774