Basic Information
| Provider Information | |||||||||
| NPI: | 1831130020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAIG | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | RANDY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | SUITE 320-330 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177815387 | ||||||||
| FaxNumber: | 4177817174 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | SUITE 320-330 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177815387 | ||||||||
| FaxNumber: | 4177817174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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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 | 207RI0011X | 103131 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 100257960B | 05 | OK | MEDICAID | 100311550G | 05 | KS | MEDICAID | P00800262 | 01 | MO | RAIL ROAD MEDICARE | OTHER | 1831130020 | 05 | MO | MEDICAID |