Provider Demographics
NPI:1003070830
Name:D/B/A WESTERN MISSOURI PEDIATRICS
Entity Type:Organization
Organization Name:D/B/A WESTERN MISSOURI PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-747-2500
Mailing Address - Street 1:415D BURKARTH RD
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-3101
Mailing Address - Country:US
Mailing Address - Phone:660-747-3141
Mailing Address - Fax:660-747-7292
Practice Address - Street 1:415D BURKARTH RD
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3101
Practice Address - Country:US
Practice Address - Phone:660-747-3141
Practice Address - Fax:660-747-7292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MISSOURI MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
221-44208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty