Provider Demographics
NPI:1043319957
Name:FAMILY MEDICINE OF JEFFERSON CITY, LLC
Entity type:Organization
Organization Name:FAMILY MEDICINE OF JEFFERSON CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAVERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-659-7300
Mailing Address - Street 1:1616 SOUTHRIDGE DR
Mailing Address - Street 2:SUITE #203
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5677
Mailing Address - Country:US
Mailing Address - Phone:573-659-7300
Mailing Address - Fax:573-636-0555
Practice Address - Street 1:1616 SOUTHRIDGE DR
Practice Address - Street 2:SUITE #203
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5677
Practice Address - Country:US
Practice Address - Phone:573-659-7300
Practice Address - Fax:573-636-0555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9J28207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty