Provider Demographics
NPI:1275751380
Name:UROLOGY MIDWEST LC
Entity Type:Organization
Organization Name:UROLOGY MIDWEST LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-826-7077
Mailing Address - Street 1:1715 S LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7541
Mailing Address - Country:US
Mailing Address - Phone:660-826-7077
Mailing Address - Fax:660-826-4202
Practice Address - Street 1:1715 S LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7541
Practice Address - Country:US
Practice Address - Phone:660-826-7077
Practice Address - Fax:660-826-4202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2015-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6D16208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO21098026OtherBLUE SHIELD
MO507785707Medicaid
MO507785707Medicaid
MO0861170001Medicare NSC