Provider Demographics
NPI:1932385952
Name:SIMPELO MEDICAL CLINIC, P.C.
Entity Type:Organization
Organization Name:SIMPELO MEDICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RUSTICO
Authorized Official - Middle Name:V
Authorized Official - Last Name:SIMPELO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-438-5408
Mailing Address - Street 1:108 FRIZZELL
Mailing Address - Street 2:SUITE 6
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664
Mailing Address - Country:US
Mailing Address - Phone:573-438-5408
Mailing Address - Fax:573-438-2419
Practice Address - Street 1:108 FRIZZELL
Practice Address - Street 2:SUITE 6
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664
Practice Address - Country:US
Practice Address - Phone:573-438-5408
Practice Address - Fax:573-438-2419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263860Medicare Oscar/Certification