Basic Information
| Provider Information | |||||||||
| NPI: | 1780625749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FURSA | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 S. NATIONAL AVE | ||||||||
| Address2: | STE. 540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172698825 | ||||||||
| FaxNumber: | 4172698744 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 N. JEFFERSON | ||||||||
| Address2: | #B100 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658021917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172698825 | ||||||||
| FaxNumber: | 4172698744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33651 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2008014375 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 2008014375 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 35131 | 01 | MIDLANDS | OTHER | 3214536 | 05 | IA | MEDICAID | P00232672 | 01 | RAILROAD MEDICARE | OTHER | 1780625749 | 05 | MO | MEDICAID | 39007 | 01 | WELLMARK BCBS | OTHER |