Healthcare Provider Details

I. General information

NPI: 1962481663
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: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 S MAIN ST
PALMYRA MO
63461-1961
US

IV. Provider business mailing address

100 MEDICAL DR
HANNIBAL MO
63401-6877
US

V. Phone/Fax

Practice location:
  • Phone: 573-769-2231
  • Fax: 573-769-3953
Mailing address:
  • Phone: 573-221-5250
  • Fax: 573-231-3706

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: MR. MICHAEL J BUKSTEIN
Title or Position: PHYSICIAN EXEC DIRECTOR
Credential: MD
Phone: 573-231-3172