Basic Information
Provider Information | |||||||||
NPI: | 1437297967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDWEST BONE & JOINT CENTER, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MIDWEST BONE & JOINT CENTER, PC MOBERLY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 795057 | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631790795 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149890300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1517 UNION AVE | ||||||||
Address2: | SUITE D | ||||||||
City: | MOBERLY | ||||||||
State: | MO | ||||||||
PostalCode: | 652709471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6603851006 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2007 | ||||||||
LastUpdateDate: | 09/23/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAIN | ||||||||
AuthorizedOfficialFirstName: | DONET | ||||||||
AuthorizedOfficialMiddleName: | CHRISTOPHER | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6603851006 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207XS0114X | 110583 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
No ID Information.