Basic Information
| Provider Information | |||||||||
| NPI: | 1851671689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-MO LUNG ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 BROOKFIELD MNR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652036246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738157118 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 BROOKFIELD MNR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652036246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738157118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 08/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | LODHI | ||||||||
| AuthorizedOfficialFirstName: | HUMAYUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5738157118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 117893 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 500193800 | 05 | MO | MEDICAID |