Provider Demographics
NPI:1639317050
Name:TRI COUNTY MEDICAL CLINIC P C
Entity Type:Organization
Organization Name:TRI COUNTY MEDICAL CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-687-3411
Mailing Address - Street 1:6601 W THORNHILL RD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:MO
Mailing Address - Zip Code:65243-9381
Mailing Address - Country:US
Mailing Address - Phone:573-687-3411
Mailing Address - Fax:573-687-3328
Practice Address - Street 1:208 N OGDEN ST
Practice Address - Street 2:BOX 367
Practice Address - City:STURGEON
Practice Address - State:MO
Practice Address - Zip Code:65284-9217
Practice Address - Country:US
Practice Address - Phone:573-687-3411
Practice Address - Fax:573-687-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8G92261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242429009Medicaid
MOA14027Medicare UPIN
MO94626Medicare PIN