| |
200 N Main St Suite 51g Rolla MO 65401-3061 | |
(573) 426-6712 | |
(573) 426-6735 |
Full Name | |
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Speciality | Family Medicine |
Location | 200 N Main St, Rolla, Missouri |
Authorized Official Name and Position | Kelly Miller (CEO) |
Authorized Official Contact | 5734266712 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
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200 N Main St Suite 51g Rolla MO 65401-3061 Ph: (573) 426-6712 | 200 N Main St Suite 51g Rolla MO 65401-3061 Ph: (573) 426-6712 |
NPI Number | 1255867479 |
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Provider Enumeration Date | 05/09/2017 |
Last Update Date | 05/09/2017 |
Identifier | Type | State | Issuer |
---|---|---|---|
1255867479 | NPI | - | NPPES |
1164669172 | Medicaid | MO |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207Q00000X | Family Medicine | (* (Not Available)) | Primary |
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