Provider Demographics
NPI:1053760769
Name:MOUNTAIN GROVE MEDICAL AND LASER CENTER INC
Entity type:Organization
Organization Name:MOUNTAIN GROVE MEDICAL AND LASER CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOYLE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-926-6643
Mailing Address - Street 1:1003 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1234
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:601 N BUSCH AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711
Practice Address - Country:US
Practice Address - Phone:417-926-6643
Practice Address - Fax:417-926-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1053760769Medicaid
MO1053760769Medicaid
MO000001328Medicare PIN