Provider Demographics
NPI:1841261153
Name:JCMG ANCILLARY SERVICES, LLC
Entity type:Organization
Organization Name:JCMG ANCILLARY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CASSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-556-1783
Mailing Address - Street 1:1241 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6023
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-636-9756
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:573-636-9756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO26D0446044291U00000X
MO006386333600000X
MO0980220261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No291U00000XLaboratoriesClinical Medical Laboratory
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2631629OtherNABP
MO718482300Medicaid
MO470000400OtherRAILROAD MEDICARE
MO2631629OtherNABP