Healthcare Provider Details

I. General information

NPI: 1659971620
Provider Name (Legal Business Name): MISSOURI RETINA CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 09/19/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N KEENE ST STE 102
COLUMBIA MO
65201-8131
US

IV. Provider business mailing address

105 N KEENE ST STE 102
COLUMBIA MO
65201-8131
US

V. Phone/Fax

Practice location:
  • Phone: 573-777-8738
  • Fax: 573-777-8739
Mailing address:
  • Phone: 573-777-8738
  • Fax: 573-777-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARI ANN ZEILER KEITHAHN
Title or Position: OWNER
Credential: MD
Phone: 573-777-8738