Basic Information
| Provider Information | |||||||||
| NPI: | 1396337473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST OB GYN OF MISSOURI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1007 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639021007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737727000 | ||||||||
| FaxNumber: | 5736861315 | ||||||||
| Practice Location | |||||||||
| Address1: | 2210 BARRON RD STE 206 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737727000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2021 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | PATTY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5737727000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDWEST OB GYN OF MISSOURI, LLC | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.