Provider Demographics
NPI:1740396035
Name:MID MISSOURI MEDICAL CONSULTANTS, INC.
Entity Type:Organization
Organization Name:MID MISSOURI MEDICAL CONSULTANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:WADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-635-7651
Mailing Address - Street 1:1111 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2753
Mailing Address - Country:US
Mailing Address - Phone:573-635-7651
Mailing Address - Fax:573-659-4515
Practice Address - Street 1:1111 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-2753
Practice Address - Country:US
Practice Address - Phone:573-635-7651
Practice Address - Fax:573-659-4515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4N29207R00000X
MOR86382084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO104047OtherBC/BS INSURANCE GROUP
MO500166806Medicaid
MO104047OtherBC/BS INSURANCE GROUP