Healthcare Provider Details

I. General information

NPI: 1437297967
Provider Name (Legal Business Name): MIDWEST BONE & JOINT CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 UNION AVE SUITE D
MOBERLY MO
65270-9471
US

IV. Provider business mailing address

PO BOX 795057
SAINT LOUIS MO
63179-0795
US

V. Phone/Fax

Practice location:
  • Phone: 660-385-1006
  • Fax:
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number110583
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DONET CHRISTOPHER MAIN
Title or Position: OWNER
Credential: DO
Phone: 660-385-1006