Basic Information
| Provider Information | |||||||||
| NPI: | 1629007208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULDER | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 802 N. RIVERSIDE RD., | ||||||||
| Address2: | STE. G50 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166714888 | ||||||||
| FaxNumber: | 8166714890 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 N RIVERSIDE RD. | ||||||||
| Address2: | STE G50 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166714888 | ||||||||
| FaxNumber: | 8166714890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 02/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | R7297 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | R7297 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 10001089301 | 01 | MO | COMMUNITY HEALTH PLAN | OTHER | P00208226 | 01 | MO | RR MEDICARE | OTHER | 100206190B | 05 | KS | MEDICAID | 201022217 | 05 | MO | MEDICAID |