Healthcare Provider Details

I. General information

NPI: 1730173964
Provider Name (Legal Business Name): RICHARD G. REBER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N OAKLAND AVE DEPT. OF RADIOLOGY
BOLIVAR MO
65613-3011
US

IV. Provider business mailing address

PO BOX 802758
KANSAS CITY MO
64180-0001
US

V. Phone/Fax

Practice location:
  • Phone: 417-328-6446
  • Fax: 417-328-6369
Mailing address:
  • Phone: 314-645-4900
  • Fax: 314-645-6548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number103708
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: