Healthcare Provider Details

I. General information

NPI: 1619145612
Provider Name (Legal Business Name): FAMILY MEDICINE OF SOUTHEAST MISSOURI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 E WAKEFIELD AVE
SIKESTON MO
63801-5147
US

IV. Provider business mailing address

808 E. WAKEFIELD AVENUE FAMILY MEDCINE OF SOUTHEAST MISSOURI
SIKESTON MO
63801-5100
US

V. Phone/Fax

Practice location:
  • Phone: 573-620-6444
  • Fax:
Mailing address:
  • Phone: 573-620-6444
  • Fax: 888-654-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number2005013758
License Number StateMO

VIII. Authorized Official

Name: VICKI JANE ROBERTS
Title or Position: OWNER
Credential: M.D.
Phone: 573-620-6444