Healthcare Provider Details

I. General information

NPI: 1003070830
Provider Name (Legal Business Name): D/B/A WESTERN MISSOURI PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415D BURKARTH RD
WARRENSBURG MO
64093-3101
US

IV. Provider business mailing address

415D BURKARTH RD
WARRENSBURG MO
64093-3101
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-3141
  • Fax: 660-747-7292
Mailing address:
  • Phone: 660-747-3141
  • Fax: 660-747-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number221-44
License Number State

VIII. Authorized Official

Name: MR. CRAIG J. MARKS
Title or Position: PRESIDENT / CEO
Credential:
Phone: 660-747-2500