MEDICARE: PHYSICIAN CORRECTIONAL USA (MO.), 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	207R00000X	Internal Medicine Physician
2	208D00000X	General Practice Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LC14503852	OTHER	MO	MISSOURI CHARTER #

General Provider Information

NPI Number	:	1548061294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN CORRECTIONAL USA (MO.), LLC

Provider Business Mailing Address
First Line	:	1650 SE 17TH ST STE 408
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33316-1740
Country	:	US
Telephone Number	:	812-499-3023
Fax Number	:	207-419-6186

Provider Business Practice Location Address
First Line	:	200 S TUCKER BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63102-1152
Country	:	US
Telephone Number	:	812-499-3023
Fax Number	:	207-419-6186

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. JAMES R MARTIN
Credential	:	MPSA, CCHP
Telephone Number	:	812-499-3023

Provider Enumeration Date	:	03/20/2025
Last Update Date	:	03/20/2025

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Directions to “PHYSICIAN CORRECTIONAL USA (MO.), LLC ” Practice Location

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