Provider Demographics
NPI:1144451063
Name:INTERNAL MEDICINE ASSOCIATES OF SOUTHEAST MISSOURI LLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF SOUTHEAST MISSOURI LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRITES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-727-5500
Mailing Address - Street 1:225 PHYSICIANS PARK
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3956
Mailing Address - Country:US
Mailing Address - Phone:573-727-5500
Mailing Address - Fax:573-686-1315
Practice Address - Street 1:225 PHYSICIANS PARK
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-727-5500
Practice Address - Fax:573-686-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263950Medicare Oscar/Certification