Basic Information
Provider Information | |||||||||
NPI: | 1437223641 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REGIONAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COXHEALTH SURGERY MONETT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4046 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658084046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4172695712 | ||||||||
FaxNumber: | 4172697567 | ||||||||
Practice Location | |||||||||
Address1: | 801 N LINCOLN AVE | ||||||||
Address2: |   | ||||||||
City: | MONETT | ||||||||
State: | MO | ||||||||
PostalCode: | 657081641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4172362440 | ||||||||
FaxNumber: | 4173541458 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 03/14/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUETOW | ||||||||
AuthorizedOfficialFirstName: | MAX | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4176310381 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 506091909 | 05 | MO |   | MEDICAID |