Provider Demographics
NPI:1629052063
Name:MEDICAL SPECIALISTS OF SOUTHEAST MISSOURI, PC
Entity Type:Organization
Organization Name:MEDICAL SPECIALISTS OF SOUTHEAST MISSOURI, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAVALLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-334-4822
Mailing Address - Street 1:PO BOX 191850
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-7850
Mailing Address - Country:US
Mailing Address - Phone:314-821-8055
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:ATTN INFECTIOUS DISEASE DEPT
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-3000
Practice Address - Fax:573-331-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100253282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital