Provider Demographics
NPI:1407266265
Name:BROOKFIELD MEDICAL CLINIC
Entity Type:Organization
Organization Name:BROOKFIELD MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUTCHINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-258-7544
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-0464
Mailing Address - Country:US
Mailing Address - Phone:660-258-7544
Mailing Address - Fax:660-258-7577
Practice Address - Street 1:308 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-1601
Practice Address - Country:US
Practice Address - Phone:660-258-7544
Practice Address - Fax:660-258-7577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO30110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO120002207OtherRAILROAD MEDICARE
MO240728717Medicaid
MO240728717Medicaid
MO001013817Medicare PIN