Provider Demographics
NPI:1790816759
Name:VIENNA FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:VIENNA FAMILY PRACTICE LLC
Other - Org Name:VIENNA FAMILY PRACTICE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SEGALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-422-3360
Mailing Address - Street 1:111 PARKWAY
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:MO
Mailing Address - Zip Code:65582-8003
Mailing Address - Country:US
Mailing Address - Phone:573-422-3360
Mailing Address - Fax:573-422-3391
Practice Address - Street 1:111 PARKWAY
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:MO
Practice Address - Zip Code:65582-8003
Practice Address - Country:US
Practice Address - Phone:573-422-3360
Practice Address - Fax:573-422-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOD0106518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508242708Medicaid
MO000012236Medicare ID - Type Unspecified