Healthcare Provider Details

I. General information

NPI: 1275766982
Provider Name (Legal Business Name): BOYCE & BYNUM - CHARITON LAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W JEFFERSON ST
KIRKSVILLE MO
63501-1443
US

IV. Provider business mailing address

200 PORTLAND ST
COLUMBIA MO
65201-6525
US

V. Phone/Fax

Practice location:
  • Phone: 660-626-2361
  • Fax: 660-626-2244
Mailing address:
  • Phone: 573-886-4600
  • Fax: 573-886-4695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL GRAY
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-886-4600