Provider Demographics
NPI:1235533498
Name:JEFFERSON CITY MEDICAL GROUP-P C
Entity Type:Organization
Organization Name:JEFFERSON CITY MEDICAL GROUP-P C
Other - Org Name:MISSOURI VALLEY PHYSICIANS A DIVISION OF JCMG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-635-5264
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-556-5757
Practice Address - Street 1:2303 S HIGHWAY 65 STE A
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3735
Practice Address - Country:US
Practice Address - Phone:660-886-3364
Practice Address - Fax:660-886-6044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1235533498Medicaid