Healthcare Provider Details

I. General information

NPI: 1508157140
Provider Name (Legal Business Name): SPRINGFIELD INTERNAL MEDICINE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2011
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 E BRADFORD PKWY SUITE 105
SPRINGFIELD MO
65804-6563
US

IV. Provider business mailing address

1435 E BRADFORD PKWY SUITE 105
SPRINGFIELD MO
65804-6563
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-4994
  • Fax: 417-881-4998
Mailing address:
  • Phone: 417-881-4994
  • Fax: 417-881-4998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2010006173
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number116600
License Number StateMO

VIII. Authorized Official

Name: KERI SUTTON
Title or Position: OWNER / NURSE PRACTITIONER
Credential: NP
Phone: 417-881-4994