MEDICARE: RETINA ASSOCIATES OF MISSOURI, P.C.

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	207WX0107X	Retina Specialist (Ophthalmology) Physician	MD108058	MO

General Provider Information

NPI Number	:	1144204553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RETINA ASSOCIATES OF MISSOURI, P.C.

Provider Business Mailing Address
First Line	:	3600 AMRON CT
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65202-1918
Country	:	US
Telephone Number	:	573-874-1616
Fax Number	:	573-875-0300

Provider Business Practice Location Address
First Line	:	3600 AMRON CT
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65202-1918
Country	:	US
Telephone Number	:	573-874-1616
Fax Number	:	573-875-0300

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JERRY R BLAIR
Credential	:	M.D.
Telephone Number	:	573-874-1616

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	12/03/2020

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