Provider Demographics
NPI:1083661615
Name:JEFFERSON CITY MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:JEFFERSON CITY MEDICAL GROUP, P.C.
Other - Org Name:FAMILY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-635-5264
Mailing Address - Street 1:1306 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LINN
Mailing Address - State:MO
Mailing Address - Zip Code:65051-2503
Mailing Address - Country:US
Mailing Address - Phone:573-897-2202
Mailing Address - Fax:573-897-3157
Practice Address - Street 1:1306 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LINN
Practice Address - State:MO
Practice Address - Zip Code:65051-2503
Practice Address - Country:US
Practice Address - Phone:573-897-2202
Practice Address - Fax:573-897-3157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCD6061OtherMEDICARE RAILROAD
MOCC7852OtherMEDICARE RAILROAD
MOCD6058OtherMEDICARE RAILROAD