Basic Information
| Provider Information | |||||||||
| NPI: | 1881647824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATTY | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2210 BARRON RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864133 | ||||||||
| FaxNumber: | 5737781099 | ||||||||
| Practice Location | |||||||||
| Address1: | 2210 BARRON RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864133 | ||||||||
| FaxNumber: | 5737781099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 05/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | R8B19 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 201645538 | 05 | MO | MEDICAID |