Provider Demographics
NPI:1043817323
Name:MISSOURI MEDICAL PROVIDERS LLC
Entity type:Organization
Organization Name:MISSOURI MEDICAL PROVIDERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:SHAFIQ
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-271-5317
Mailing Address - Street 1:2215 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4403
Mailing Address - Country:US
Mailing Address - Phone:573-271-5317
Mailing Address - Fax:573-335-6724
Practice Address - Street 1:10 LAKE DR
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1820
Practice Address - Country:US
Practice Address - Phone:573-358-2800
Practice Address - Fax:573-358-1090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500090302Medicaid
MO1043817323OtherNPI