Provider Demographics
NPI:1346513207
Name:JEFFERSON CITY MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:JEFFERSON CITY MEDICAL GROUP, PC
Other - Org Name:JCMG AT THE LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
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:
Practice Address - Street 1:5816 OSAGE BEACH PKWY STE 105
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3046
Practice Address - Country:US
Practice Address - Phone:573-348-3001
Practice Address - Fax:573-348-5998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8640207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty