Healthcare Provider Details

I. General information

NPI: 1477532182
Provider Name (Legal Business Name): HANNIBAL CLINIC OPERATIONS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 HIGHWAY 24 AND 36 E
MONROE CITY MO
63456-1470
US

IV. Provider business mailing address

100 MEDICAL DR
HANNIBAL MO
63401-6877
US

V. Phone/Fax

Practice location:
  • Phone: 573-735-2506
  • Fax: 573-231-3706
Mailing address:
  • Phone: 573-221-5250
  • Fax: 573-231-3706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDY JOBE
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-231-3172