# CARROLL COUNTY MEDICAL CLINIC

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

## Provider details

- **NPI number:** 1366752768
- **Authorized official:** JERRY DOVER (CEO)
- **Authorized official phone:** (660) 542-1695

## Contact information

- **Practice address:** 1502 N JEFFERSON ST, ST SUITE A B, CARROLLTON, MO 64633-1948
- **Practice address phone:** (660) 542-3865
- **Practice address fax:** (660) 542-0336
- **Mailing address:** 1502 N JEFFERSON ST, SUITE A B, CARROLLTON, MO 64633-1948
- **Mailing address phone:** (660) 542-3865
- **Mailing address fax:** (660) 542-0336

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | MD106594 | MO | Yes |
| 207Q00000X | Family Medicine Physician | MD109202 | MO | — |
| 207R00000X | Internal Medicine Physician | MD106594 | MO | — |
| 2080A0000X | Pediatric Adolescent Medicine Physician | MD109202 | MO | — |

## Other

- **Enumeration date:** 10/19/2010
- **Last updated:** 10/19/2010