MEDICARE: MISSOURI EAR NOSE AND THROAT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1033319140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI EAR NOSE AND THROAT CENTER

Provider Business Mailing Address
First Line	:	3401 BERRYWOOD DR
Second Line	:	SUITE 201
City	:	COLUMBIA
State	:	MO
Zip	:	65201-6515
Country	:	US
Telephone Number	:	573-815-0662
Fax Number	:	573-443-1162

Provider Business Practice Location Address
First Line	:	3401 BERRYWOOD DR
Second Line	:	SUITE 201
City	:	COLUMBIA
State	:	MO
Zip	:	65201-6515
Country	:	US
Telephone Number	:	573-815-0662
Fax Number	:	573-443-1162

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. WILLIAM CHARLES KINNEY SR.
Credential	:	MD
Telephone Number	:	573-808-0492

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	07/18/2007

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