Healthcare Provider Details

I. General information

NPI: 1508056540
Provider Name (Legal Business Name): PCRMC MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

PO BOX 579
ROLLA MO
65402-0579
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-3431
  • Fax: 573-458-3433
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN DENBO
Title or Position: CEO
Credential:
Phone: 573-458-8899