Healthcare Provider Details

I. General information

NPI: 1164932893
Provider Name (Legal Business Name): PHYSICIAN MANAGEMENT SERVICES OF SOUTHERN MISSOURI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 PERUQUE CROSSING CT
O FALLON MO
63366-2362
US

IV. Provider business mailing address

3113 LAWTON RD STE 250
ORLANDO FL
32803-3517
US

V. Phone/Fax

Practice location:
  • Phone: 888-829-8550
  • 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

VIII. Authorized Official

Name: BRETT KENEFICK
Title or Position: PRESIDENT
Credential:
Phone: 888-829-8550