Healthcare Provider Details

I. General information

NPI: 1376560383
Provider Name (Legal Business Name): MEDICAL & SURGICAL SPECIALISTS OF ROLLA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BLUES LAKE PKWY
ROLLA MO
65401-8022
US

IV. Provider business mailing address

600 BLUES LAKE PKWY
ROLLA MO
65401-8022
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-8822
  • Fax: 573-341-5969
Mailing address:
  • Phone: 573-364-8822
  • Fax: 573-341-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD KRENNING
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 573-364-8822