Organization
PHYSICIAN SERVICES OF MISSOURI LLC
Active
Parent organization
VAXCARE CORPORATION
Organization subpart
Yes
Provider details
NPI number
Legal business name
VAXCARE CORPORATION
Authorized official
CASEY DELOACH (MANAGER)
(888) 829-8550
Entity
Organization
Contact information
Practice address
1611 S BALTIMORE ST, KIRKSVILLE, MO 63501-4536
(859) 514-5547
(859) 422-4907
Mailing address
989 GOVERNORS LN, SUITE 160, LEXINGTON, KY 40513-1173
(859) 514-5547
(859) 422-4907
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PHC059
MEDICARE PTAN
—
Enumeration date
01/09/2012
Last updated
01/09/2012
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