1407052616 NPI number — ROBERT L SWEETEN MD INC

Table of content: (NPI 1407052616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407052616 NPI number — ROBERT L SWEETEN MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT L SWEETEN MD INC
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:
SWEETEN MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
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:
1407052616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4725
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:
64803-4725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-451-7425
Provider Business Mailing Address Fax Number:
417-451-7455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1355 ROCKETDYNE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEOSHO
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64850-3106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-451-7425
Provider Business Practice Location Address Fax Number:
417-451-7455
Provider Enumeration Date:
06/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SWEETEN
Authorized Official First Name:
TINA
Authorized Official Middle Name:
RENE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
417-540-6798

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  12749 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 2007032918 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000015453 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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