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General NPI Number Information
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NPI Number | 1619145612
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICINE OF SOUTHEAST MISSOURI, LLC
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Dates
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Enumeration Date | 02/13/2008
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Last Update Date | 09/08/2011
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Provider Practice Location Address
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Address Line | 808 E WAKEFIELD AVE
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City | SIKESTON
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State | MO
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Zip | 63801-5147
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Country | US
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Telephone | 573-620-6444
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Fax |
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Provider Business Mailing Address
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Address Line | 808 E. WAKEFIELD AVENUE FAMILY MEDCINE OF SOUTHEAST MISSOURI
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City | SIKESTON
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State | MO
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Zip | 63801-5100
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Country | US
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Telephone | 573-620-6444
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Fax | 888-654-6599
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Authorized Official
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Title or Position | OWNER
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Name | VICKI JANE ROBERTS
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Credential | M.D.
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Telephone | 573-620-6444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 2005013758
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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