Basic Information
| Provider Information | |||||||||
| NPI: | 1952348690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BYNUM | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615065 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 E WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737777500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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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 | 207Q00000X | 36421 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104036 | 01 | MO | UNITED HEALTHCARE | OTHER | 130835 | 01 | MO | HEALTHLINK | OTHER | 2486843301 | 01 | MO | KANSAS MEDICAID | OTHER | 100463 | 01 | MO | BLUE SHIELD | OTHER | 100463 | 01 | MO | BLUE CHOICE | OTHER | 241825744 | 05 | MO | MEDICAID |