Provider Demographics
NPI:1649269663
Name:PHYSICIANS ALLIANCE LC
Entity type:Organization
Organization Name:PHYSICIANS ALLIANCE LC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:BANDERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-1222
Mailing Address - Street 1:3241 PERCY DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4901
Mailing Address - Country:US
Mailing Address - Phone:573-334-1222
Mailing Address - Fax:573-334-3532
Practice Address - Street 1:3241 PERCY DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4901
Practice Address - Country:US
Practice Address - Phone:573-334-1222
Practice Address - Fax:573-334-3532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104-16261QM1300X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000040045Medicare ID - Type Unspecified