Provider Demographics
NPI:1861579013
Name:PATTERSON FAMILY PRACTICE
Entity type:Organization
Organization Name:PATTERSON FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:636-464-4000
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-0998
Mailing Address - Country:US
Mailing Address - Phone:636-464-4000
Mailing Address - Fax:636-464-4911
Practice Address - Street 1:1502 PREHISTORIC HILL DR
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-2288
Practice Address - Country:US
Practice Address - Phone:636-464-4000
Practice Address - Fax:636-464-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODG3276OtherRAILROAD MEDICARE