Provider Demographics
NPI:1750625844
Name:SOUTHERN MISSOURI INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:SOUTHERN MISSOURI INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JEFFERY
Authorized Official - Last Name:MCNABB
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-335-5057
Mailing Address - Street 1:3260 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2609
Mailing Address - Country:US
Mailing Address - Phone:573-335-5057
Mailing Address - Fax:573-335-1552
Practice Address - Street 1:3260 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2609
Practice Address - Country:US
Practice Address - Phone:573-335-5057
Practice Address - Fax:573-335-1552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO100129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203716006Medicaid
MOF14056Medicare UPIN
MO000001532Medicare PIN