Provider Demographics
NPI:1235311796
Name:JEFFERSON CITY OBSTETRICS & GYNECOLOGY INC
Entity Type:Organization
Organization Name:JEFFERSON CITY OBSTETRICS & GYNECOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KWEI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-893-5500
Mailing Address - Street 1:2712 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2712 PLAZA DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-1147
Practice Address - Country:US
Practice Address - Phone:573-893-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119368207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4014040Medicare UPIN