Provider Demographics
NPI:1396876355
Name:KIRKSVILLE ACADEMIC MEDICINE LLC
Entity type:Organization
Organization Name:KIRKSVILLE ACADEMIC MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:800 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-1443
Mailing Address - Country:US
Mailing Address - Phone:660-626-2235
Mailing Address - Fax:660-626-2090
Practice Address - Street 1:800 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-1443
Practice Address - Country:US
Practice Address - Phone:660-626-2235
Practice Address - Fax:660-626-2090
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIRKSVILLE ACADEMIC MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-08
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X, 207RC0000X, 363LF0000X, 207R00000X
208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0765826Medicaid
MO218276OtherANTHEM BCBS
MO504459702Medicaid
IA0765826Medicaid
MO000015384Medicare PIN
IAI20314Medicare PIN