Healthcare Provider Details

I. General information

NPI: 1639178445
Provider Name (Legal Business Name): GRANT MICHAEL BARNUM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 BAGNELL DAM BLVD
LAKE OZARK MO
65049-8658
US

IV. Provider business mailing address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-365-2318
  • Fax: 573-365-3009
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberDOR4GO2
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: