Provider Demographics
NPI:1417959149
Name:MEDSTOP ONE INC
Entity Type:Organization
Organization Name:MEDSTOP ONE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-335-4100
Mailing Address - Street 1:3065 WILLIAM ST
Mailing Address - Street 2:STE 209
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6393
Mailing Address - Country:US
Mailing Address - Phone:573-335-4100
Mailing Address - Fax:573-339-7887
Practice Address - Street 1:3065 WILLIAM ST
Practice Address - Street 2:SUITE 209
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6393
Practice Address - Country:US
Practice Address - Phone:573-335-4100
Practice Address - Fax:573-339-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO175986OtherHEALTHLINK
MO218453OtherBLUE CROSS
MO593915200Medicaid
MO263889Medicare ID - Type Unspecified
MO218453OtherBLUE CROSS