Provider Demographics
NPI:1326232851
Name:MOBERLY AREA OSTEOPATHIC CLINIC, INC
Entity Type:Organization
Organization Name:MOBERLY AREA OSTEOPATHIC CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-588-3420
Mailing Address - Street 1:3308 THORNBIRD ST
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-9644
Mailing Address - Country:US
Mailing Address - Phone:816-588-3420
Mailing Address - Fax:816-988-8333
Practice Address - Street 1:3308 THORNBIRD ST
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-9644
Practice Address - Country:US
Practice Address - Phone:816-588-3420
Practice Address - Fax:816-988-8333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOBERLY AREA OSTEOPATHIC CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-28
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000165578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502240708Medicaid
MOH46529Medicare UPIN
MO13673Medicare PIN