Healthcare Provider Details

I. General information

NPI: 1922087121
Provider Name (Legal Business Name): CENTRAL MISSOURI NEPHROLOGY ASSOCIATES,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CLUB VILLAGE DR STE 102
COLUMBIA MO
65203-4411
US

IV. Provider business mailing address

1100 CLUB VILLAGE DR STE 102
COLUMBIA MO
65203-4411
US

V. Phone/Fax

Practice location:
  • Phone: 573-447-4400
  • Fax: 573-303-0140
Mailing address:
  • Phone: 573-447-4400
  • Fax: 573-303-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR2H47
License Number StateMO

VIII. Authorized Official

Name: DR. SUNDER M LAL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 573-447-4400