=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902448426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 417 RHEUMATOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2019
-----------------------------------------------------
Last Update Date | 06/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 E REPUBLIC RD STE D200
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65807-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-501-2644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 E REPUBLIC RD STE D200
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65807-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-501-2644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | RYAN CADY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-501-2644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------