Provider Demographics
NPI:1336309228
Name:EDGAR M CONRAD IV, LLC
Entity Type:Organization
Organization Name:EDGAR M CONRAD IV, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:IV
Authorized Official - Credentials:DO
Authorized Official - Phone:414-782-3292
Mailing Address - Street 1:2700 CUNNINGHAM AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-1570
Mailing Address - Country:US
Mailing Address - Phone:417-782-3292
Mailing Address - Fax:417-782-4024
Practice Address - Street 1:2700 CUNNINGHAM AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1570
Practice Address - Country:US
Practice Address - Phone:417-782-3292
Practice Address - Fax:417-782-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107748207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO248016636Medicaid
MO248016636Medicaid