Provider Demographics
NPI:1629022215
Name:INTERNAL MEDICINE ASSOCIATES OF SOUTHEAST MISSOURI LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF SOUTHEAST MISSOURI LLC
Other - Org Name:PHYSICIANS PARK PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:F.
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-727-5500
Mailing Address - Street 1:225 PHYSICIANS PARK
Mailing Address - Street 2:SUITE 400
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3956
Mailing Address - Country:US
Mailing Address - Phone:573-727-5500
Mailing Address - Fax:573-778-0581
Practice Address - Street 1:225 PHYSICIANS PARK
Practice Address - Street 2:SUITE 400
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-727-5500
Practice Address - Fax:573-778-0581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505183400Medicaid
MOCB3531Medicare PIN
MO000013328Medicare PIN