Healthcare Provider Details

I. General information

NPI: 1871105312
Provider Name (Legal Business Name): 417 SPORTS MEDICINE AND ORTHOPEDICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3328 S NATIONAL AVE
SPRINGFIELD MO
65807-7305
US

IV. Provider business mailing address

2100 E NORSHIRE ST
SPRINGFIELD MO
65804-7829
US

V. Phone/Fax

Practice location:
  • Phone: 417-771-3147
  • Fax:
Mailing address:
  • Phone: 817-825-5096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC GIFFORD
Title or Position: PHYSICIAN
Credential: MD
Phone: 817-825-5096