Provider Demographics
NPI:1558323386
Name:TINSLEY MEDICAL CLINIC
Entity Type:Organization
Organization Name:TINSLEY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:TINSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-686-1144
Mailing Address - Street 1:2400 LUCY LEE PKWY
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2429
Mailing Address - Country:US
Mailing Address - Phone:573-686-1144
Mailing Address - Fax:573-686-3312
Practice Address - Street 1:2400 LUCY LEE PKWY
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2429
Practice Address - Country:US
Practice Address - Phone:573-686-1144
Practice Address - Fax:573-686-3312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34610207Q00000X
MO261QR1300X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO3941210001OtherDME NUMBER
MO5076174600Medicaid
MO3941210001OtherDME NUMBER
MO990001599Medicare ID - Type UnspecifiedGROUP #