Provider Demographics
NPI:1306017769
Name:MT. AUBURN MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:MT. AUBURN MEDICAL GROUP, LLC
Other - Org Name:MT. AUBURN MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:BIESER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-335-2212
Mailing Address - Street 1:150 S MOUNT AUBURN RD
Mailing Address - Street 2:SUITE 342
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4911
Mailing Address - Country:US
Mailing Address - Phone:573-335-2212
Mailing Address - Fax:573-339-5946
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:SUITE 342
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4911
Practice Address - Country:US
Practice Address - Phone:573-335-2212
Practice Address - Fax:573-339-5946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104929207Q00000X
MO1004971207Q00000X
MO116768207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174611966OtherJEFFREY W. CHILDERS, MD
MO1386732196OtherROBERT D. BIESER, DO
MO1467542571OtherPHILIP E. TIPPEN, MD
MOH00955Medicare UPIN
MO1467542571OtherPHILIP E. TIPPEN, MD
MO1174611966OtherJEFFREY W. CHILDERS, MD