=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619208303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKAGGS-COX HEALTH ALLIANCE, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2010
-----------------------------------------------------
Last Update Date | 06/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 BRANSON HILLS PKWY
-----------------------------------------------------
City | BRANSON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65616-9942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-336-0536
-----------------------------------------------------
Fax | 417-336-0539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4046
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65808-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-269-5712
-----------------------------------------------------
Fax | 417-269-4869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | ROBERT H. BEZANSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-269-3108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------