Provider Demographics
NPI:1508840901
Name:MID-MISSOURI INTERNAL MEDICINE INC
Entity Type:Organization
Organization Name:MID-MISSOURI INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:LEANNE
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-364-7545
Mailing Address - Street 1:1050 W 10TH ST STE 550
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-7545
Mailing Address - Fax:573-368-3672
Practice Address - Street 1:1050 W 10TH ST STE 550
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-364-7545
Practice Address - Fax:573-368-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34425207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1436867OtherUNITED HEALTHCARE
MODG8365OtherMEDICARE TRAVELERS
MO123495OtherBLUE CROSS BLUE SHIELD
MO1013100866OtherPROVIDER NPI
MO504474602Medicaid
MO004050080Medicare Oscar/Certification
MO1013100866OtherPROVIDER NPI
MO000015420Medicare PIN