Provider Demographics
NPI:1093012890
Name:PCRMC MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PCRMC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-458-7615
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0579
Mailing Address - Country:US
Mailing Address - Phone:573-458-3425
Mailing Address - Fax:573-426-2282
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:STE 420
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-458-3425
Practice Address - Fax:573-426-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMODOR4D88174400000X
MO2009011768213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty