Healthcare Provider Details

I. General information

NPI: 1700952462
Provider Name (Legal Business Name): CLYDE R. REDMOND II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W MAPLE AVE STE 403
SPRINGDALE AR
72764-5374
US

IV. Provider business mailing address

100 MERCY WAY SUITE 310
JOPLIN MO
64804-4524
US

V. Phone/Fax

Practice location:
  • Phone: 479-757-4840
  • Fax:
Mailing address:
  • Phone: 417-556-8600
  • Fax: 417-556-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0438216
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number28924
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number2000156468
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: