Provider Demographics
NPI:1265476006
Name:CENTRAL MISSOURI CARDIOLOGY, P.C.
Entity Type:Organization
Organization Name:CENTRAL MISSOURI CARDIOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ARLA
Authorized Official - Middle Name:G
Authorized Official - Last Name:QUALLS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:573-636-0635
Mailing Address - Street 1:3501 A WEST TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109
Mailing Address - Country:US
Mailing Address - Phone:573-636-0635
Mailing Address - Fax:573-659-4685
Practice Address - Street 1:3501 A WEST TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-636-0635
Practice Address - Fax:573-659-4685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504645102Medicaid
MO000012615Medicare PIN