Healthcare Provider Details

I. General information

NPI: 1396797494
Provider Name (Legal Business Name): LYLE G. BREEDING, MD, FACS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 KEENE ST
COLUMBIA MO
65201-6625
US

IV. Provider business mailing address

401 KEENE ST
COLUMBIA MO
65201-6625
US

V. Phone/Fax

Practice location:
  • Phone: 573-874-3300
  • Fax: 573-876-1663
Mailing address:
  • Phone: 573-874-3300
  • Fax: 573-876-1663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR9N91
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberR9N91
License Number StateMO

VIII. Authorized Official

Name: LYLE G. BREEDING
Title or Position: PRESIDENT
Credential: MD
Phone: 573-874-3300