Healthcare Provider Details

I. General information

NPI: 1225021231
Provider Name (Legal Business Name): SPRINGFIELD PHYSICAL MEDICINE AND REHABILITATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 N GLENSTONE AVE
SPRINGFIELD MO
65802-2130
US

IV. Provider business mailing address

1308 N GLENSTONE AVE
SPRINGFIELD MO
65802-2130
US

V. Phone/Fax

Practice location:
  • Phone: 417-864-4100
  • Fax: 417-863-8697
Mailing address:
  • Phone: 417-864-4100
  • Fax: 417-863-8697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES C MAULDIN JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 417-864-4100