MEDICARE: SPRINGFIELD PHYSICAL MEDICINE AND REHABILITATION, INC

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	261QU0200X	Urgent Care Clinic/Center
2	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1225021231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRINGFIELD PHYSICAL MEDICINE AND REHABILITATION, INC

Provider Business Mailing Address
First Line	:	1308 N GLENSTONE AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-2130
Country	:	US
Telephone Number	:	417-864-4100
Fax Number	:	417-863-8697

Provider Business Practice Location Address
First Line	:	1308 N GLENSTONE AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-2130
Country	:	US
Telephone Number	:	417-864-4100
Fax Number	:	417-863-8697

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES C MAULDIN JR.
Credential	:	M.D.
Telephone Number	:	417-864-4100

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	09/27/2007

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