Basic Information
| Provider Information | |||||||||
| NPI: | 1700967429 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANTHONY ZOFFUTO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1286 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652051286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005406575 | ||||||||
| FaxNumber: | 5734999418 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 SAINT FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637035049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | WHITESIDES | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8005406575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | R4523 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CK6400 | 01 | RAILROAD MEDICARE | OTHER |