Basic Information
| Provider Information | |||||||||
| NPI: | 1588677991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTOM | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3800 S NATIONAL AVE | ||||||||
| Address2: | STE. 540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172362600 | ||||||||
| FaxNumber: | 4172362619 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E. CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | MONETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657086149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172362600 | ||||||||
| FaxNumber: | 4172362619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 11/14/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 112771 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E5435 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 128131 | 01 | BLUE CROSS MO | OTHER | 204965602 | 05 | MO | MEDICAID |