MEDICARE: MD2U MISSOURI 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1477867034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MD2U MISSOURI LLC

Provider Business Mailing Address
First Line	:	105 CRESCENT AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40206-1525
Country	:	US
Telephone Number	:	502-327-9100
Fax Number	:	502-618-4990

Provider Business Practice Location Address
First Line	:	111 W PORT PLZ
Second Line	:	6TH FLOOR
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3011
Country	:	US
Telephone Number	:	502-327-9100
Fax Number	:	502-618-4990

Authorized Official
Title or Position	:	MANAGER
Name	:	JERRY MICHAEL BENFIELD JR.
Credential	:	M.D.
Telephone Number	:	502-327-9100

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	08/05/2010

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