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General NPI Number Information
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NPI Number | 1770693277
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Entity Type | Organization
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Legal Business Name | OSAGE BEACH CARDIOLOGY LTD
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 04/02/2018
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Provider Practice Location Address
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Address Line | 162 CRESCENT BLF
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City | CAMDENTON
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State | MO
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Zip | 65020-3828
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Country | US
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Telephone | 573-480-4186
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1087
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City | OSAGE BEACH
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State | MO
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Zip | 65065-1087
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Country | US
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Telephone | 573-480-4186
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TIMOTHY JOSEPH MCDERMOTT
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Credential | M.D.
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Telephone | 573-480-4497
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | R3N07
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License Number State | MO
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