Provider Demographics
NPI:1205889227
Name:SEMO GYNECOLOGY LLC
Entity type:Organization
Organization Name:SEMO GYNECOLOGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:F
Authorized Official - Last Name:PATTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-686-4133
Mailing Address - Street 1:2210 BARRON RD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1908
Mailing Address - Country:US
Mailing Address - Phone:573-686-4133
Mailing Address - Fax:573-778-1099
Practice Address - Street 1:2210 BARRON RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1908
Practice Address - Country:US
Practice Address - Phone:573-686-4133
Practice Address - Fax:573-778-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201645538Medicaid
MO000014128Medicare PIN
MOA11461Medicare UPIN