# JEFFERSON PHYSICIAN NETWORK, LLC

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

## Provider details

- **NPI number:** 1568734994
- **Authorized official:** MR. JEFF BUCK (INTERIEM CHIEF EXECUTIVE OFFICER)
- **Authorized official phone:** (636) 933-1000

## Contact information

- **Practice address:** 1105 W LIBERTY ST, FARMINGTON, MO 63640-1921
- **Practice address phone:** (636) 933-2900
- **Practice address fax:** (636) 933-8017
- **Mailing address:** PO BOX 350, CRYSTAL CITY, MO 63019-0350
- **Mailing address phone:** (636) 933-1299
- **Mailing address fax:** (636) 933-8017

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | 2009008025 | MO | Yes |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | 2010010722 | MO | — |
| 207RR0500X | Rheumatology Physician | 2009017530 | MO | — |

## Other

- **Enumeration date:** 02/01/2012
- **Last updated:** 02/01/2012