Provider Demographics
NPI:1336279454
Name:SEDALIA INTERNAL MEDICINE SPECIALISTS PC
Entity Type:Organization
Organization Name:SEDALIA INTERNAL MEDICINE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:R
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-827-2526
Mailing Address - Street 1:1712 S LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7542
Mailing Address - Country:US
Mailing Address - Phone:660-827-2526
Mailing Address - Fax:660-827-5536
Practice Address - Street 1:1712 S LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7542
Practice Address - Country:US
Practice Address - Phone:660-827-2526
Practice Address - Fax:660-827-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501695605Medicaid
MO09962017OtherBLUE SHIELD PROVIDER NUMB
MO501695605Medicaid