Basic Information
| Provider Information | |||||||||
| NPI: | 1790722437 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | NEVILLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1027 | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651021027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737617246 | ||||||||
| FaxNumber: | 5737616947 | ||||||||
| Practice Location | |||||||||
| Address1: | 2511 W EDGEWOOD DR | ||||||||
| Address2: | STE D | ||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651095869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737612121 | ||||||||
| FaxNumber: | 5736350726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 09/28/2012 | ||||||||
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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 | R4P82 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | R4P82 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 205754807 | 05 | MO | MEDICAID | 205958408 | 05 | MO | MEDICAID | 104984 | 01 | MO | UNITED HEALTHCARE | OTHER | 2086335801 | 01 | MO | KANSAS MEDICAID | OTHER | 40006670 | 01 | MO | RR MEDICARE | OTHER | 102869 | 01 | MO | HEALTHLINK | OTHER |