Basic Information
Provider Information | |||||||||
NPI: | 1619208303 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SKAGGS-COX HEALTH ALLIANCE, LLC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE CLINIC AT WAL-MART OPERATED BY COX HEALTH IN PARTNERSHIP WITH SKAG | ||||||||
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: | 4172694869 | ||||||||
Practice Location | |||||||||
Address1: | 1101 BRANSON HILLS PKWY | ||||||||
Address2: |   | ||||||||
City: | BRANSON | ||||||||
State: | MO | ||||||||
PostalCode: | 656169942 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4173360536 | ||||||||
FaxNumber: | 4173360539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2010 | ||||||||
LastUpdateDate: | 06/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEZANSON | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | H. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 4172693108 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COX HEALTH ALLIANCE LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.