Provider Demographics
NPI:1851682025
Name:IMMEDIATE CONVENIENT CARE-PERRYVILLE, LLC
Entity type:Organization
Organization Name:IMMEDIATE CONVENIENT CARE-PERRYVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCIAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BALSANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-331-5228
Mailing Address - Street 1:1702 N KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2122
Mailing Address - Country:US
Mailing Address - Phone:573-339-2000
Mailing Address - Fax:573-339-1876
Practice Address - Street 1:1508 EDGEMONT BLVD
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1231
Practice Address - Country:US
Practice Address - Phone:573-517-7555
Practice Address - Fax:573-517-7556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT FRANCIS HEALTHCARE SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty