Basic Information
| Provider Information | |||||||||
| NPI: | 1033291125 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LESTER E. COX MEDICAL CENTERS | ||||||||
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| OtherOrganizationName: | SOUTHWEST SPINE & SPORTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 S NATIONAL AVE | ||||||||
| Address2: | #540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172696262 | ||||||||
| FaxNumber: | 4172694349 | ||||||||
| Practice Location | |||||||||
| Address1: | 3555 S NATIONAL AVE | ||||||||
| Address2: | #302 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658077310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172696868 | ||||||||
| FaxNumber: | 4172696865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4172696262 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 508089703 | 05 | MO | MEDICAID | 146825 | 01 | BLUE CROSS OF MO | OTHER |