Healthcare Provider Details

I. General information

NPI: 1720073638
Provider Name (Legal Business Name): WELLPOINTE FAMILY MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 W HUBBLE DR
MARSHFIELD MO
65706-1532
US

IV. Provider business mailing address

PO BOX 817
CAPE GIRARDEAU MO
63702-0817
US

V. Phone/Fax

Practice location:
  • Phone: 417-859-7746
  • Fax: 417-859-7411
Mailing address:
  • Phone: 573-335-4715
  • Fax: 573-334-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WARD M LAWSON
Title or Position: PHD PRESIDENT
Credential: PHD
Phone: 417-859-7746