Provider Demographics
NPI:1447239157
Name:HANNIBAL CLINIC OPERATIONS, L.L.C.
Entity Type:Organization
Organization Name:HANNIBAL CLINIC OPERATIONS, L.L.C.
Other - Org Name:HANNIBAL CLINIC @ MONROE CITY
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN EXEC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUKSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-231-3172
Mailing Address - Street 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6877
Mailing Address - Country:US
Mailing Address - Phone:573-221-5250
Mailing Address - Fax:573-231-3824
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE CITY
Practice Address - State:MO
Practice Address - Zip Code:63456-1318
Practice Address - Country:US
Practice Address - Phone:573-735-4541
Practice Address - Fax:573-735-2143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013771OtherPTAN
4721210004Medicare NSC
MO000013771OtherPTAN