Healthcare Provider Details

I. General information

NPI: 1053308718
Provider Name (Legal Business Name): MICHAEL STEPHEN HANKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PRIMROSE STE 320
SPRINGFIELD MO
65807
US

IV. Provider business mailing address

1000 E PRIMROSE STE 320
SPRINGFIELD MO
65807
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-2300
  • Fax: 417-269-2315
Mailing address:
  • Phone: 417-269-2300
  • Fax: 417-269-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMRD1G32
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier13538
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerBLUE CROSS BLUESHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: