Basic Information
| Provider Information | |||||||||
| NPI: | 1790062859 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPRINGFIELD NEUROLOGICAL AND SPINE INSTITUTE | ||||||||
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| OtherOrganizationName: | SPRINGFIELD NEUROLOGICAL AND SPINE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1423 N JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658021917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3215 N NORTHHILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2011 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | BUETOW | ||||||||
| AuthorizedOfficialFirstName: | MAX | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICS | ||||||||
| AuthorizedOfficialTelephone: | 4178853888 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LESTER E. COX MEDICAL CENTERS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.