Provider Demographics
NPI:1477532182
Name:HANNIBAL CLINIC OPERATIONS, L.L.C.
Entity Type:Organization
Organization Name:HANNIBAL CLINIC OPERATIONS, L.L.C.
Other - Org Name:MONROE CITY FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOBE
Authorized Official - Suffix:
Authorized Official - Credentials:
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:573-231-3706
Practice Address - Street 1:821 HIGHWAY 24 AND 36 E
Practice Address - Street 2:
Practice Address - City:MONROE CITY
Practice Address - State:MO
Practice Address - Zip Code:63456-1470
Practice Address - Country:US
Practice Address - Phone:573-735-2506
Practice Address - Fax:573-231-3706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013771Medicare ID - Type Unspecified
4721210004Medicare NSC