Healthcare Provider Details

I. General information

NPI: 1366496515
Provider Name (Legal Business Name): MATTHEW J CONCANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 FALLING LEAF CT
COLUMBIA MO
65201-3579
US

IV. Provider business mailing address

3115 FALLING LEAF CT
COLUMBIA MO
65201-3579
US

V. Phone/Fax

Practice location:
  • Phone: 573-449-5000
  • Fax: 573-449-5010
Mailing address:
  • Phone: 573-449-5000
  • Fax: 573-449-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMDR7H73
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: