Provider Demographics
NPI:1083897862
Name:JEFFERSON CITY MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:JEFFERSON CITY MEDICAL GROUP, PC
Other - Org Name:JCMG FAMILY HEALTH 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:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5246
Mailing Address - Fax:
Practice Address - Street 1:606 E BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-1910
Practice Address - Country:US
Practice Address - Phone:573-796-3600
Practice Address - Fax:573-796-7251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty