Healthcare Provider Details

I. General information

NPI: 1831486661
Provider Name (Legal Business Name): CATHERINE EDELE BENBOW D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 N JEFFERSON AVE STE B100
SPRINGFIELD MO
65802-1917
US

IV. Provider business mailing address

1423 N JEFFERSON AVE STE B100
SPRINGFIELD MO
65802-1917
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-8817
  • Fax: 417-269-8744
Mailing address:
  • Phone: 417-269-8817
  • Fax: 417-269-8744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011018667
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: