Healthcare Provider Details

I. General information

NPI: 1053805531
Provider Name (Legal Business Name): ZACH ROBERT BOAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 FARAON ST
SAINT JOSEPH MO
64506-3488
US

IV. Provider business mailing address

EMERGENCY MEDICINE DEPARTMENT 14 MEDICAL PARK, STE 350
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-6000
  • Fax:
Mailing address:
  • Phone: 803-434-7088
  • Fax: 803-434-3946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberLL52792
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021016111
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: