Healthcare Provider Details

I. General information

NPI: 1326497587
Provider Name (Legal Business Name): IPC PAC HEALTHCARE SERVICES OF MISSOURI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12101 WOODCREST EXECUTIVE DR SUITE 210
SAINT LOUIS MO
63141-5047
US

IV. Provider business mailing address

265 BROOKVIEW CENTRE WAY STE 400
KNOXVILLE TN
37919-4052
US

V. Phone/Fax

Practice location:
  • Phone: 314-317-0600
  • Fax:
Mailing address:
  • Phone: 865-693-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDAL DABBS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 865-693-1000