=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487908117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME CARE FAMILY MEDICINE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2012
-----------------------------------------------------
Last Update Date | 11/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 E HICKORY ST
-----------------------------------------------------
City | NEOSHO
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-451-4545
-----------------------------------------------------
Fax | 417-451-4546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 220
-----------------------------------------------------
City | NEOSHO
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64850-0220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-451-4545
-----------------------------------------------------
Fax | 417-451-4546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CRAIG L PENDERGRASS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 417-451-4545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 110888
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------