1770591752 NPI number — COLUMBIA ORAL & MAXILLOFACIAL SURGERY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770591752 NPI number — COLUMBIA ORAL & MAXILLOFACIAL SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBIA ORAL & MAXILLOFACIAL SURGERY LLC
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:
1770591752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 W NIFONG BLVD
Provider Second Line Business Mailing Address:
BLDG 4 STE 100
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65203-5661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-443-0466
Provider Business Mailing Address Fax Number:
573-442-5417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 W NIFONG BLVD
Provider Second Line Business Practice Location Address:
BLDG 4 STE 100
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65203-5661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-443-0466
Provider Business Practice Location Address Fax Number:
573-442-5417
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDREWS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
ADAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
573-443-0466

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , 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)





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