1174572770 NPI number — NORTHEAST MISSOURI PHYSICIANS SERVICES

Table of content: (NPI 1174572770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174572770 NPI number — NORTHEAST MISSOURI PHYSICIANS SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST MISSOURI PHYSICIANS SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174572770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/11/2006
NPI Reactivation Date:
06/08/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41878
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19101-1878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-444-7009
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 S OSTEOPATHY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIRKSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63501-6401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-785-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT, EPP
Authorized Official Telephone Number:
800-444-7009

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 183342 . This is a "BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".