Provider Demographics
NPI:1881819464
Name:ROLLA URGENT CARE LLC
Entity Type:Organization
Organization Name:ROLLA URGENT CARE LLC
Other - Org Name:ROLLA URGENT CARE RURAL HEALTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DEL. OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:OLUYOMI
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLUSANYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-426-5900
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0817
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:1060 S BISHOP AVE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4411
Practice Address - Country:US
Practice Address - Phone:573-426-5900
Practice Address - Fax:573-426-4466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROLLA URGENT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2002009086207R00000X
261QR1300X
124268363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268956Medicare PIN