1821201641 NPI number — SPRINGFIELD EYE & PLASTIC SURGERY

Table of content: (NPI 1821201641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821201641 NPI number — SPRINGFIELD EYE & PLASTIC SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGFIELD EYE & PLASTIC SURGERY
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:
1821201641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 70
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OZARK
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65721-0070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-837-4238
Provider Business Mailing Address Fax Number:
417-875-4728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2828 N NATIONAL AVE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65803-4306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-837-4238
Provider Business Practice Location Address Fax Number:
417-875-4728
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DELPORT
Authorized Official First Name:
BRENDON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-496-3664

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  2004008249 , 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: 209165604 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1194721100 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: DO5151 . This is a "RR MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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