Provider Demographics
NPI:1215030713
Name:JEFFERSON MEDICAL GROUP
Entity Type:Organization
Organization Name:JEFFERSON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:IRELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-329-6005
Mailing Address - Street 1:1502 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1948
Mailing Address - Country:US
Mailing Address - Phone:660-542-9998
Mailing Address - Fax:660-542-9880
Practice Address - Street 1:1502 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1948
Practice Address - Country:US
Practice Address - Phone:660-542-9998
Practice Address - Fax:660-542-9880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO50899330Medicaid
MOW600000Medicare PIN