MEDICARE: MISSOURI MEDICAL PROVIDERS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363L00000X	Nurse Practitioner
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
3	163WW0000X	Wound Care Registered Nurse
4	363LF0000X	Family Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043817323	OTHER	MO	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043817323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI MEDICAL PROVIDERS LLC

Provider Business Mailing Address
First Line	:	2215 BROADWAY ST
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-4403
Country	:	US
Telephone Number	:	636-725-1255
Fax Number	:	573-534-3131

Provider Business Practice Location Address
First Line	:	2215 BROADWAY ST
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-4403
Country	:	US
Telephone Number	:	636-725-1255
Fax Number	:	573-534-3131

Authorized Official
Title or Position	:	OWNER
Name	:	OMER MALIK
Credential	:
Telephone Number	:	636-725-1255

Provider Enumeration Date	:	10/08/2020
Last Update Date	:	10/16/2025

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Directions to “MISSOURI MEDICAL PROVIDERS LLC ” Practice Location

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