Provider Demographics
NPI:1649332156
Name:CHERYL G WILLIAMS DO PC
Entity type:Organization
Organization Name:CHERYL G WILLIAMS DO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-466-7191
Mailing Address - Street 1:1011 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1331
Mailing Address - Country:US
Mailing Address - Phone:417-466-7191
Mailing Address - Fax:417-466-3876
Practice Address - Street 1:1011 S EAST ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1331
Practice Address - Country:US
Practice Address - Phone:417-466-7191
Practice Address - Fax:417-466-3876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
MO113916261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO590665907Medicaid
MO590665907Medicaid
MOH15905Medicare UPIN
MO268946Medicare ID - Type UnspecifiedRIVERBEND MEDICARE