Basic Information
| Provider Information | |||||||||
| NPI: | 1588874242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RATCHFORD | ||||||||
| FirstName: | NATHAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | ATTN; EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733649000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733649000 | ||||||||
| FaxNumber: | 5732022460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 2004016537 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 1588874242 | 05 | MO | MEDICAID | 431560263 | 01 | TRICARE WEST | OTHER | 11876195 | 01 | CAQH PROVIDER # | OTHER |