Provider Demographics
NPI:1376560383
Name:MEDICAL & SURGICAL SPECIALISTS OF ROLLA, INC.
Entity Type:Organization
Organization Name:MEDICAL & SURGICAL SPECIALISTS OF ROLLA, INC.
Other - Org Name:BOND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KRENNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-364-8822
Mailing Address - Street 1:600 BLUES LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8022
Mailing Address - Country:US
Mailing Address - Phone:573-364-8822
Mailing Address - Fax:573-341-5969
Practice Address - Street 1:600 BLUES LAKE PKWY
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-8022
Practice Address - Country:US
Practice Address - Phone:573-364-8822
Practice Address - Fax:573-341-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503052706Medicaid
GADA5531OtherRAIL ROAD MEDICARE
TN5002700001Medicare NSC
MO503052706Medicaid