Basic Information
| Provider Information | |||||||||
| NPI: | 1386026706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAVERMALE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172249484 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1150 STATE HIGHWAY 248 STE 202 | ||||||||
| Address2: | |||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656163729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173352299 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2015 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125.0067324 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2018012786 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200070827 | 05 | MO | MEDICAID |