Healthcare Provider Details

I. General information

NPI: 1366521429
Provider Name (Legal Business Name): BONNE TERRE MEDICAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N ALLEN ST
BONNE TERRE MO
63628-1210
US

IV. Provider business mailing address

30 N ALLEN ST
BONNE TERRE MO
63628-1210
US

V. Phone/Fax

Practice location:
  • Phone: 573-358-3343
  • Fax:
Mailing address:
  • Phone: 573-358-3343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number36676
License Number StateMO

VIII. Authorized Official

Name: MR. DAVID A MULLEN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 573-358-3343