1487792917 NPI number — MIDWEST BONE & JOINT CENTER, PC

Table of content: (NPI 1487792917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487792917 NPI number — MIDWEST BONE & JOINT CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST BONE & JOINT CENTER, PC
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:
6
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:
1487792917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 795057
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63179-0795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-989-0300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROUTE 11 WEST
Provider Second Line Business Practice Location Address:
TIMBERLINE CLINIC
Provider Business Practice Location Address City Name:
KIRKSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-385-1006
Provider Business Practice Location Address Fax Number:
660-385-1028
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAIN
Authorized Official First Name:
DONET
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
660-385-1006

Provider Taxonomy Codes

  • Taxonomy code: 207XS0114X , with the licence number:  110583 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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