Healthcare Provider Details

I. General information

NPI: 1639200942
Provider Name (Legal Business Name): EBBY GEORGE VARGHESE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 09/12/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 S PROVIDENCE RD BLDG. C
COLUMBIA MO
65203-3644
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-7100
  • Fax: 573-884-7706
Mailing address:
  • Phone: 573-882-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number2005021816
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: