Provider Demographics
NPI:1083078786
Name:MCCOY, WILLIAM
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:MCCOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-1801
Mailing Address - Country:US
Mailing Address - Phone:573-290-2841
Mailing Address - Fax:573-290-2881
Practice Address - Street 1:415 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-1801
Practice Address - Country:US
Practice Address - Phone:573-290-2841
Practice Address - Fax:573-290-2881
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO81-2146580OtherEIN NUMBER