Provider Demographics
NPI:1528116910
Name:PRIMARY CARE MEDICINE PC
Entity type:Organization
Organization Name:PRIMARY CARE MEDICINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ERICH
Authorized Official - Last Name:SCHAFERMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-635-2141
Mailing Address - Street 1:2709 INDUSTRIAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-0769
Mailing Address - Country:US
Mailing Address - Phone:573-635-2141
Mailing Address - Fax:573-635-5240
Practice Address - Street 1:2709 INDUSTRIAL DR STE A
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-0769
Practice Address - Country:US
Practice Address - Phone:573-635-2141
Practice Address - Fax:573-635-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO106076207Q00000X
MODO33555207Q00000X
MOR8652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504013509Medicaid
CI8553OtherRAILROAD MEDICARE
MO504013509Medicaid