Provider Demographics
NPI:1053509356
Name:BROOKFIELD FAMILY HEALTH CLINIC PC
Entity Type:Organization
Organization Name:BROOKFIELD FAMILY HEALTH CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MNANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-258-3363
Mailing Address - Street 1:624 W LOCKLING ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-2003
Mailing Address - Country:US
Mailing Address - Phone:660-258-3363
Mailing Address - Fax:660-258-5409
Practice Address - Street 1:624 W. LOCKLING ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-2336
Practice Address - Country:US
Practice Address - Phone:660-258-3363
Practice Address - Fax:660-258-5409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506793702Medicaid
MO506793702Medicaid