NPIMap

Organization Active NPI

Primary Care of Bonne Terre LLC

  • General Practice Physician
  • Bonne Terre, MO
National Provider Identifier
1962883751
Registry record updated Nov 23, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
PRIMARY CARE OF BONNE TERRE LLC
Practice address
527 Benham St
Bonne Terre, MO 63628-1205
Phone
(573) 358-9119
Fax
(573) 358-9489
NPI assigned
Jun 17, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 23, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Andrew J Ninichuck, MDNPI 1609841956
Title
Owner
Phone
(573) 358-9119

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X Primary
Primary Care Clinic/Center 261QP2300X

Addresses

Primary practice location

527 Benham St
Bonne Terre, MO 63628-1205

Mailing address

527 Benham St
Bonne Terre, MO 63628-1205
Phone (573) 358-9119

Other names 1

  • Primary Care of Bonne Terre Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20151210001830 MO Part B Supplier - Clinic/Group Practice 4183925415 Receives reassigned benefits from 2 practitioners
Practice locations: Bonne Terre, MO

National Provider Directory

National Provider Directory

Locations

527 Benham St
Bonne Terre, MO 63628
Phone (573) 358-5577

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1434499200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1448236800000",
    "number": "1962883751",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "527 BENHAM ST",
            "city": "BONNE TERRE",
            "state": "MO",
            "postal_code": "636281205",
            "telephone_number": "573-358-9119",
            "fax_number": "573-358-9489"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "527 BENHAM ST",
            "city": "BONNE TERRE",
            "state": "MO",
            "postal_code": "636281205",
            "telephone_number": "573-358-9119",
            "fax_number": "573-358-9489"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIMARY CARE OF BONNE TERRE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-17",
        "last_updated": "2015-11-23",
        "status": "A",
        "authorized_official_last_name": "NINICHUCK",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "573-358-9119",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Primary Care of Bonne Terre",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bonne Terre, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 23, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.