Provider Demographics
NPI:1811063936
Name:PHYSICIAN GROUPS, LC
Entity type:Organization
Organization Name:PHYSICIAN GROUPS, LC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-996-7690
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-7644
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:1600 N MORLEY ST
Practice Address - Street 2:SUITE A120
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-3666
Practice Address - Country:US
Practice Address - Phone:660-263-1225
Practice Address - Fax:660-263-1613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000012470Medicare PIN