MEDICARE: JACKSON PRIMARY CARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207V00000X	Obstetrics & Gynecology Physician
2	261QR1300X	Rural Health Clinic/Center
3	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	132588	OTHER	MO	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619961380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	2685 E MAIN ST SUITE A
Second Line	:	STE A
City	:	JACKSON
State	:	MO
Zip	:	63755
Country	:	US
Telephone Number	:	573-204-1400
Fax Number	:	573-204-1480

Provider Business Practice Location Address
First Line	:	2685 E MAIN ST SUITE A
Second Line	:	STE A
City	:	JACKSON
State	:	MO
Zip	:	63755
Country	:	US
Telephone Number	:	573-204-1400
Fax Number	:	573-204-1480

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DEANNA M SIEMER
Credential	:	MD
Telephone Number	:	573-204-1400

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	10/26/2010

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Directions to “JACKSON PRIMARY CARE LLC ” Practice Location

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