MEDICARE: GERIATRIC AND PRIMARY CARE SERVICES S C

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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	036111926	IL

General Provider Information

NPI Number	:	1174535900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERIATRIC AND PRIMARY CARE SERVICES S C

Provider Business Mailing Address
First Line	:	PO BOX 752
Second Line	:
City	:	CONCORDIA
State	:	MO
Zip	:	64020-0752
Country	:	US
Telephone Number	:	660-463-1365
Fax Number	:	660-463-1367

Provider Business Practice Location Address
First Line	:	1606 CASTLEBERRY DR
Second Line	:
City	:	MARION
State	:	IL
Zip	:	62959-1586
Country	:	US
Telephone Number	:	618-997-9519
Fax Number	:	618-993-0592

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GLADSTONE A TUCKER
Credential	:	MD
Telephone Number	:	618-542-6152

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	07/25/2012

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