Provider Demographics
NPI:1407032287
Name:SOUTHERN MISSOURI ORTHOPAEDICS AND SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:SOUTHERN MISSOURI ORTHOPAEDICS AND SPORTS MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPAEDIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-255-2880
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-0586
Mailing Address - Country:US
Mailing Address - Phone:417-255-2880
Mailing Address - Fax:417-255-2860
Practice Address - Street 1:1609 PORTER WAGONER BLVD
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-1805
Practice Address - Country:US
Practice Address - Phone:417-255-2880
Practice Address - Fax:417-255-2860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8G91207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCG3756Medicare PIN
MO5283960001Medicare NSC