Healthcare Provider Details

I. General information

NPI: 1063739159
Provider Name (Legal Business Name): PLASTIC AND RECONSTRUCTIVE SURGERY OF MID-MISSOURI, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E BROADWAY SUITE 304
COLUMBIA MO
65201-8018
US

IV. Provider business mailing address

1701 E BROADWAY SUITE 304
COLUMBIA MO
65201-8018
US

V. Phone/Fax

Practice location:
  • Phone: 573-876-1700
  • Fax: 573-876-1705
Mailing address:
  • Phone: 573-876-1700
  • Fax: 573-876-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberR5577
License Number StateMO

VIII. Authorized Official

Name: RICHARD ROYER
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-777-1191