MEDICARE: FAMILY HEALTH MEDICAL PRACTICE 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	261Q00000X	Clinic/Center		MO
2	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1861405599
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY HEALTH MEDICAL PRACTICE LLC

Provider Business Mailing Address
First Line	:	825 S HIGHWAY 13
Second Line	:
City	:	LEXINGTON
State	:	MO
Zip	:	64067-1515
Country	:	US
Telephone Number	:	660-259-2240
Fax Number	:	660-259-2250

Provider Business Practice Location Address
First Line	:	825 S HIGHWAY 13
Second Line	:
City	:	LEXINGTON
State	:	MO
Zip	:	64067-1515
Country	:	US
Telephone Number	:	660-259-2240
Fax Number	:	660-259-2250

Authorized Official
Title or Position	:	OWNER
Name	:	VICKI L FOLSOM
Credential	:	DO
Telephone Number	:	660-259-2240

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	11/11/2010

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