Healthcare Provider Details

I. General information

NPI: 1033160734
Provider Name (Legal Business Name): BRENT W MIEDEMA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOSPITAL DR # 617
COLUMBIA MO
65201-5275
US

IV. Provider business mailing address

800 HOSPITAL DR # 617
COLUMBIA MO
65201-5275
US

V. Phone/Fax

Practice location:
  • Phone: 573-814-6346
  • Fax:
Mailing address:
  • Phone: 573-814-6346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMDR7N00
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: