1942605175 NPI number — MISSOURI CANCER ASSOCIATES, LLC

Table of content: (NPI 1942605175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942605175 NPI number — MISSOURI CANCER ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOURI CANCER ASSOCIATES, 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:
UROLOGY ASSOCIATES OF CENTRAL MISSOURI
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:
1942605175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1705 E BROADWAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65201-7166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-874-7800
Provider Business Mailing Address Fax Number:
573-874-8620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 N KEENE ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65201-8131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-499-4990
Provider Business Practice Location Address Fax Number:
573-442-2120
Provider Enumeration Date:
10/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TUNGESVIK
Authorized Official First Name:
MARK
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
573-874-7800

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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