Provider Demographics
NPI:1164792032
Name:PHYSICIAN SERVICES OF MISSOURI LLC
Entity Type:Organization
Organization Name:PHYSICIAN SERVICES OF MISSOURI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DELOACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-829-8550
Mailing Address - Street 1:989 GOVERNORS LN
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1173
Mailing Address - Country:US
Mailing Address - Phone:859-514-5547
Mailing Address - Fax:859-422-4907
Practice Address - Street 1:1611 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4536
Practice Address - Country:US
Practice Address - Phone:859-514-5547
Practice Address - Fax:859-422-4907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAXCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PHC059OtherMEDICARE PTAN