MEDICARE: MCPHERSON MEDICAL & DIAGNOSTIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1003407883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCPHERSON MEDICAL & DIAGNOSTIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 12545
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4016
Country	:	US
Telephone Number	:	573-276-3884
Fax Number	:	573-276-3885

Provider Business Practice Location Address
First Line	:	1207 N DOUGLASS ST
Second Line	:
City	:	MALDEN
State	:	MO
Zip	:	63863-1351
Country	:	US
Telephone Number	:	573-276-3884
Fax Number	:	573-276-3885

Authorized Official
Title or Position	:	OWNER
Name	:	TIMOTHY WILLIAM MCPHERSON
Credential	:	DO
Telephone Number	:	573-695-2181

Provider Enumeration Date	:	02/03/2021
Last Update Date	:	02/03/2021

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