MEDICARE: DR. MARK JEFFERY MCNABB D.O.

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	DO100129	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6504	OTHER	MO	ANTHEM BLUE CROSS BLUE SH

General Provider Information

NPI Number	:	1942337522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK JEFFERY MCNABB D.O.

Provider Business Mailing Address
First Line	:	3260 LEXINGTON AVE
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-2609
Country	:	US
Telephone Number	:	573-335-5057
Fax Number	:	573-335-1552

Provider Business Practice Location Address
First Line	:	3260 LEXINGTON AVE
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-2609
Country	:	US
Telephone Number	:	573-335-5057
Fax Number	:	573-335-1552

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/08/2007

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