MEDICARE: EXECUTIVE PULMONARY MEDICINE, PC

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	207R00000X	Internal Medicine Physician	2003009194	MO

General Provider Information

NPI Number	:	1720041197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE PULMONARY MEDICINE, PC

Provider Business Mailing Address
First Line	:	PO BOX 1087
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63902-1087
Country	:	US
Telephone Number	:	573-785-4601
Fax Number	:	573-686-0178

Provider Business Practice Location Address
First Line	:	1906A GREENWOOD DR
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-2430
Country	:	US
Telephone Number	:	573-776-7740
Fax Number	:	573-776-7750

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DENNIS DANIELS
Credential	:	MD
Telephone Number	:	573-776-7740

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	08/22/2020

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