Provider Demographics
NPI:1710400221
Name:JEFFERSON CITY MEDICAL GROUP, PC
Entity type:Organization
Organization Name:JEFFERSON CITY MEDICAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:ASTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-556-7774
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-5771
Mailing Address - Fax:573-636-9756
Practice Address - Street 1:606 E BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-1910
Practice Address - Country:US
Practice Address - Phone:573-796-3600
Practice Address - Fax:573-796-7251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid