Basic Information
Provider Information | |||||||||
NPI: | 1942390695 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LESTER E. COX MEDICAL CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVA FAMILY HEALTH CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3800 S NATIONAL AVE | ||||||||
Address2: | #540 | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658075209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4172696262 | ||||||||
FaxNumber: | 4172694349 | ||||||||
Practice Location | |||||||||
Address1: | 806 SW 13TH AVE | ||||||||
Address2: |   | ||||||||
City: | AVA | ||||||||
State: | MO | ||||||||
PostalCode: | 65608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4176837200 | ||||||||
FaxNumber: | 4176830165 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2006 | ||||||||
LastUpdateDate: | 09/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAYLOR | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | P. | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4172696262 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 505978502 | 05 | MO |   | MEDICAID | 116756 | 01 |   | BLUE CROSS OF MO | OTHER |