# EBO MD LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1326503376
- **Authorized official:** GENNI L OURTH (MANAGER)
- **Authorized official phone:** (573) 803-2941

## Contact information

- **Practice address:** 1417 N MOUNT AUBURN RD STE A, CAPE GIRARDEAU, MO 63701-2171
- **Practice address phone:** (573) 803-2941
- **Practice address fax:** (573) 803-0815
- **Mailing address:** 1417 N MOUNT AUBURN RD STE A, CAPE GIRARDEAU, MO 63701-2171
- **Mailing address phone:** (573) 803-2941
- **Mailing address fax:** (573) 803-0815

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 02/04/2019
- **Last updated:** 02/04/2019