Provider Demographics
NPI:1003904079
Name:MISSOURI STATE UNIVERSITY PT CLINIC
Entity Type:Organization
Organization Name:MISSOURI STATE UNIVERSITY PT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:VERE
Authorized Official - Last Name:HALLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:417-836-3070
Mailing Address - Street 1:901 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65897-0027
Mailing Address - Country:US
Mailing Address - Phone:417-836-3070
Mailing Address - Fax:
Practice Address - Street 1:606 E CHERRY ST
Practice Address - Street 2:ROOM 100
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-3401
Practice Address - Country:US
Practice Address - Phone:417-836-3070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy