Provider Demographics
NPI:1467742452
Name:JEFFERSON MEDICAL GROUP
Entity Type:Organization
Organization Name:JEFFERSON MEDICAL GROUP
Other - Org Name:JEFFERSON MEDICAL GROUP NORBORNE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:IRELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-329-6005
Mailing Address - Street 1:1502 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1948
Mailing Address - Country:US
Mailing Address - Phone:660-542-9998
Mailing Address - Fax:660-542-9880
Practice Address - Street 1:105 E 2ND ST
Practice Address - Street 2:
Practice Address - City:NORBORNE
Practice Address - State:MO
Practice Address - Zip Code:64668-1301
Practice Address - Country:US
Practice Address - Phone:660-593-3623
Practice Address - Fax:660-593-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO596573204Medicaid
MO50899330Medicaid