Provider Demographics
NPI:1215031737
Name:OSAGE FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:OSAGE FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-302-0670
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:1191 HIGHWAY KK
Practice Address - Street 2:SUITE 202
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3510
Practice Address - Country:US
Practice Address - Phone:573-302-0670
Practice Address - Fax:573-302-0677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1E19207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013558Medicare PIN