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General NPI Number Information
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NPI Number | 1619302957
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Entity Type | Organization
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Legal Business Name | MID-MISSOURI DERMATOLOGISTS, INC
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Dates
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Enumeration Date | 09/05/2013
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Last Update Date | 09/05/2013
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Provider Practice Location Address
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Address Line | 1504 E BROADWAY
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City | COLUMBIA
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State | MO
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Zip | 65201-8077
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Country | US
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Telephone | 573-442-3565
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Fax | 573-443-2172
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Provider Business Mailing Address
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Address Line | 1504 E BROADWAY
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City | COLUMBIA
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State | MO
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Zip | 65201-8077
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Country | US
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Telephone | 573-442-3565
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Fax | 573-443-2172
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERRY EDWARD FOOTE
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Credential | M.D.
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Telephone | 573-442-3565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 30179
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License Number State | MO
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