Provider Demographics
NPI:1194820860
Name:EUREKA MEDICAL LLC
Entity Type:Organization
Organization Name:EUREKA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLING OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:PITTENGER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:636-938-6060
Mailing Address - Street 1:97 HILL TOP VILLAGE CENTER
Mailing Address - Street 2:SUITE E & F
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1184
Mailing Address - Country:US
Mailing Address - Phone:636-938-6060
Mailing Address - Fax:636-587-9712
Practice Address - Street 1:97 HILL TOP VILLAGE CENTER
Practice Address - Street 2:SUITE E & F
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-1184
Practice Address - Country:US
Practice Address - Phone:636-938-6060
Practice Address - Fax:636-587-9712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOD030648207Q00000X
MO2002004657207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501125900Medicaid
MO000014219Medicare ID - Type Unspecified
MO501125900Medicaid