Provider Demographics
NPI:1548061294
Name:PHYSICIAN CORRECTIONAL USA (MO.), LLC
Entity type:Organization
Organization Name:PHYSICIAN CORRECTIONAL USA (MO.), LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MPSA, CCHP
Authorized Official - Phone:812-499-3023
Mailing Address - Street 1:1650 SE 17TH ST STE 408
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1740
Mailing Address - Country:US
Mailing Address - Phone:812-499-3023
Mailing Address - Fax:207-419-6186
Practice Address - Street 1:200 S TUCKER BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63102-1152
Practice Address - Country:US
Practice Address - Phone:812-499-3023
Practice Address - Fax:207-419-6186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOLC14503852OtherMISSOURI CHARTER #