Provider Demographics
NPI:1114235041
Name:PCRMC MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:PCRMC MEDICAL GROUP, INC
Other - Org Name:PHELPS HEALTH MEDICAL GROUP VIENNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-458-7916
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402
Mailing Address - Country:US
Mailing Address - Phone:573-426-2182
Mailing Address - Fax:573-426-5341
Practice Address - Street 1:606 HIGHWAY 63 S
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:MO
Practice Address - Zip Code:65582-8101
Practice Address - Country:US
Practice Address - Phone:573-422-3636
Practice Address - Fax:573-422-3434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PCRMC MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-14
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007024375261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO594328304Medicaid
MO268908Medicare Oscar/Certification