Provider Demographics
NPI:1568734994
Name:JEFFERSON PHYSICIAN NETWORK, LLC
Entity Type:Organization
Organization Name:JEFFERSON PHYSICIAN NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIEM CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-933-1000
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63019-0350
Mailing Address - Country:US
Mailing Address - Phone:636-933-1299
Mailing Address - Fax:636-933-8017
Practice Address - Street 1:1105 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1921
Practice Address - Country:US
Practice Address - Phone:636-933-2900
Practice Address - Fax:636-933-8017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009008025207RE0101X
MO2010010722207RE0101X
MO2009017530207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1558508606OtherNPI