Healthcare Provider Details

I. General information

NPI: 1609912443
Provider Name (Legal Business Name): ALLEN E. NORTHERN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 N BISHOP AVE
ROLLA MO
65401-2249
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-8100
  • Fax: 573-341-9475
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR5474
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: