NPIMap

Organization Active NPI

Jefferson City Medical Group, P.C.

Doing business as Jefferson City Dermatology

  • Dermatology Physician
  • Jefferson City, MO
National Provider Identifier
1972668903
Registry record updated Dec 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
JEFFERSON CITY MEDICAL GROUP, P.C.
Doing business as
Jefferson City Dermatology
Practice address
1241 W Stadium Blvd
Suite 1407
Jefferson City, MO 65109-6023
Phone
(573) 635-5264
NPI assigned
Dec 27, 2006
Last updated
Dec 26, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 26, 2018

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

Authorized official

Name
Dr. Jeffrey Lee Patrick, M.D.
Title
President
Phone
(573) 635-5264

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

1241 W Stadium Blvd
Suite 1407
Jefferson City, MO 65109-6023

Mailing address

PO Box 104240
Jefferson City, MO 65110-4240

Other identifiers 1

IdentifierTypeStateIssuer
CD6059OtherMOMEDICARE RAILROAD

Other names 1

  • Jefferson City Dermatology Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040901000004 MO Part B Supplier - Clinic/Group Practice 1850371089 Receives reassigned benefits from 10 practitioners
2 other NPIs on this enrollment
Practice locations: Jefferson Cty, MO; Jefferson City, MO

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Jeffferson City Medical12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1167177600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1545782400000",
    "number": "1972668903",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 104240",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651104240"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1241 W STADIUM BLVD",
            "address_2": "SUITE 1407",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651096023",
            "telephone_number": "573-635-5264"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON CITY MEDICAL GROUP, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-27",
        "last_updated": "2018-12-26",
        "status": "A",
        "authorized_official_last_name": "PATRICK",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "573-635-5264",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "CD6059",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jefferson City Dermatology",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Jefferson City Dermatology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jefferson City, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 26, 2018; 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.