Provider Demographics
| NPI: | 1538155817 |
|---|---|
| Name: | KIRKSVILLE CLINIC CORP |
| Entity type: | Organization |
| Organization Name: | KIRKSVILLE CLINIC CORP |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | VICE PRESIDENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | BRIAN |
| Authorized Official - Middle Name: | A |
| Authorized Official - Last Name: | PEOPLES |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 615-465-7585 |
| Mailing Address - Street 1: | PO BOX 689022 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | FRANKLIN |
| Mailing Address - State: | TN |
| Mailing Address - Zip Code: | 37068-9022 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 615-465-8575 |
| Mailing Address - Fax: | 615-465-3007 |
| Practice Address - Street 1: | 1607 S BALTIMORE ST |
| Practice Address - Street 2: | |
| Practice Address - City: | KIRKSVILLE |
| Practice Address - State: | MO |
| Practice Address - Zip Code: | 63501-4536 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 660-627-3363 |
| Practice Address - Fax: | 660-785-1927 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | KIRKSVILLE CLINIC CORP |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2005-09-22 |
| Last Update Date: | 2012-06-27 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
| No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
| No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MO | 191271 | Other | BCBS |
| IA | 1538155817 | Medicaid | |
| MO | 507437101 | Medicaid | |
| MO | MA1557 | Medicare PIN | |
| MO | 000014342 | Medicare PIN | |
| MO | DC3917 | Medicare PIN |
