Healthcare Provider Details

I. General information

NPI: 1457371072
Provider Name (Legal Business Name): STEPHEN C TINES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 NW 1ST LN
LAMAR MO
64759-8105
US

IV. Provider business mailing address

29 NW 1ST LN
LAMAR MO
64759-8105
US

V. Phone/Fax

Practice location:
  • Phone: 417-681-5100
  • Fax: 417-681-5521
Mailing address:
  • Phone: 417-681-5100
  • Fax: 417-681-5521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number16304
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR5B34
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: