1407032287 NPI number — SOUTHERN MISSOURI ORTHOPAEDICS AND SPORTS MEDICINE CLINIC

Table of content: (NPI 1407032287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407032287 NPI number — SOUTHERN MISSOURI ORTHOPAEDICS AND SPORTS MEDICINE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MISSOURI ORTHOPAEDICS AND SPORTS MEDICINE CLINIC
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:
1407032287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 586
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PLAINS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65775-0586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-255-2880
Provider Business Mailing Address Fax Number:
417-255-2860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1609 PORTER WAGONER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PLAINS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65775-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-255-2880
Provider Business Practice Location Address Fax Number:
417-255-2860
Provider Enumeration Date:
01/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
RICK
Authorized Official Middle Name:
B
Authorized Official Title or Position:
ORTHOPAEDIC PHYSICIAN
Authorized Official Telephone Number:
417-255-2880

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  R8G91 , 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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