Healthcare Provider Details

I. General information

NPI: 1780852384
Provider Name (Legal Business Name): ROLLA CHILDREN'S CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W 10TH ST SUITE 480
ROLLA MO
65401-2905
US

IV. Provider business mailing address

1050 W 10TH ST SUITE 480
ROLLA MO
65401-2905
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-1900
  • Fax: 573-364-7365
Mailing address:
  • Phone: 573-364-1900
  • Fax: 573-364-7365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. ROBERT BRUCE RUSSELL
Title or Position: MANAGER
Credential:
Phone: 573-364-1900