Provider Demographics
NPI:1326099417
Name:ROLLA URGENT CARE, LLC
Entity Type:Organization
Organization Name:ROLLA URGENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DEL OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:OLUYOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUSANYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-426-5900
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0817
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:1060 S BISHOP AVE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4411
Practice Address - Country:US
Practice Address - Phone:573-426-5900
Practice Address - Fax:573-426-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002009086207R00000X
261QR1300X
MO124268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268956Medicare Oscar/Certification
MO000014967Medicare PIN