Provider Demographics
NPI:1871598391
Name:SIKESTON URGENT CARE PC
Entity type:Organization
Organization Name:SIKESTON URGENT CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALYWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLUTTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-471-8500
Mailing Address - Street 1:918 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4416
Mailing Address - Country:US
Mailing Address - Phone:573-471-8500
Mailing Address - Fax:573-471-8501
Practice Address - Street 1:918 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4416
Practice Address - Country:US
Practice Address - Phone:573-471-8500
Practice Address - Fax:573-471-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO268920261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO598319606Medicaid
MOA10139Medicare UPIN
MO598319606Medicaid