Basic Information
| Provider Information | |||||||||
| NPI: | 1326497587 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IPC PAC HEALTHCARE SERVICES OF MISSOURI INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 BROOKVIEW CENTRE WAY | ||||||||
| Address2: | STE 400 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379194052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656931000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12101 WOODCREST EXECUTIVE DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 07/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | DABBS | ||||||||
| AuthorizedOfficialFirstName: | RANDAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8656931000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.