Provider Demographics
NPI:1366752768
Name:CARROLL COUNTY MEDICAL CLINIC
Entity type:Organization
Organization Name:CARROLL COUNTY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-542-1695
Mailing Address - Street 1:1502 N JEFFERSON ST
Mailing Address - Street 2:SUITE A B
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1948
Mailing Address - Country:US
Mailing Address - Phone:660-542-3865
Mailing Address - Fax:660-542-0336
Practice Address - Street 1:1502 N JEFFERSON ST
Practice Address - Street 2:ST SUITE A B
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1948
Practice Address - Country:US
Practice Address - Phone:660-542-3865
Practice Address - Fax:660-542-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD109202207Q00000X, 2080A0000X
MOMD106594207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty