Provider Demographics
NPI:1992800635
Name:THE SUTHERLAND CLINIC LLC
Entity type:Organization
Organization Name:THE SUTHERLAND CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-327-6407
Mailing Address - Street 1:221 N MAIN ST
Mailing Address - Street 2:PO BOX 206
Mailing Address - City:PARIS
Mailing Address - State:MO
Mailing Address - Zip Code:65275-1328
Mailing Address - Country:US
Mailing Address - Phone:660-327-6416
Mailing Address - Fax:660-327-6217
Practice Address - Street 1:221 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:MO
Practice Address - Zip Code:65275-1328
Practice Address - Country:US
Practice Address - Phone:660-327-6416
Practice Address - Fax:660-327-6217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO245101407Medicaid
MO000094803Medicare ID - Type Unspecified
MO245101407Medicaid