1215337118 NPI number — HOMETOWN PEDIATRICS OF JOPLIN

Table of content: (NPI 1215337118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215337118 NPI number — HOMETOWN PEDIATRICS OF JOPLIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOMETOWN PEDIATRICS OF JOPLIN
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:
1215337118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2302 E 32ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64804-4301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-626-7337
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 CASTLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-9115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
141-762-6733
Provider Business Practice Location Address Fax Number:
417-626-0600
Provider Enumeration Date:
08/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
SHARI
Authorized Official Middle Name:
LYNNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-626-7337

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100303350B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 248898710 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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