Healthcare Provider Details

I. General information

NPI: 1912904632
Provider Name (Legal Business Name): MICHAEL WAYNE COLEMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N COLLEGE ST
ALBANY MO
64402-1432
US

IV. Provider business mailing address

606 N COLLEGE ST
ALBANY MO
64402-1432
US

V. Phone/Fax

Practice location:
  • Phone: 660-726-5592
  • Fax: 660-726-3992
Mailing address:
  • Phone: 660-726-5592
  • Fax: 660-726-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number110838
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: