Healthcare Provider Details

I. General information

NPI: 1194704080
Provider Name (Legal Business Name): RALPH FORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35629 HIGHWAY 72
SALEM MO
65560-7217
US

IV. Provider business mailing address

PO BOX 774 35629 HIGHWAY 72
SALEM MO
65560-0774
US

V. Phone/Fax

Practice location:
  • Phone: 573-729-6626
  • Fax: 573-729-6502
Mailing address:
  • Phone: 573-729-6626
  • Fax: 573-729-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number252 30
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: