Provider Demographics
NPI:1316178189
Name:AMAVISCA, JOSEPH ALBERT (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ALBERT
Last Name:AMAVISCA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-277-3960
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6877
Practice Address - Country:US
Practice Address - Phone:573-221-5250
Practice Address - Fax:573-221-3706
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD156341207Q00000X
MO2025012600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500672860Medicaid
OR161133OtherNBMC GROUP MEDICAID
OR930635514OtherNBMC GROUP TAX ID FOR BILLING
ORR0000WFBTVOtherNBMC GROUP MEDICARE #
OR500672860Medicaid
ORR164919Medicare PIN