Healthcare Provider Details

I. General information

NPI: 1104807635
Provider Name (Legal Business Name): TAMON BERBER PAIGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5265 S BUSINESS 71 STE A
PINEVILLE MO
65865
US

IV. Provider business mailing address

PO BOX 2526
JOPLIN MO
64803-2526
US

V. Phone/Fax

Practice location:
  • Phone: 417-223-5300
  • Fax:
Mailing address:
  • Phone: 417-347-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMO116659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: