Provider Demographics
NPI:1225163116
Name:PRIMROSE NEPHROLOGY, INC.
Entity Type:Organization
Organization Name:PRIMROSE NEPHROLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-823-2900
Mailing Address - Street 1:1540 E EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4300
Mailing Address - Country:US
Mailing Address - Phone:417-823-2900
Mailing Address - Fax:417-886-2774
Practice Address - Street 1:1540 E EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4300
Practice Address - Country:US
Practice Address - Phone:417-823-2900
Practice Address - Fax:417-886-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO112417174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500967807Medicaid
MOB76552Medicare UPIN
MO500967807Medicaid