Provider Demographics
NPI:1437377538
Name:PACE, MICHAEL J JR
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PACE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 W HICKORY ST
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-1705
Practice Address - Country:US
Practice Address - Phone:417-451-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4490207P00000X, 207Q00000X
MO2016017569207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200115370AMedicaid
MO206321200Medicaid
MO500359203Medicaid
OK200059690AMedicaid
OK200059690AMedicaid
P00414845Medicare PIN
243724903Medicare PIN
DC3959Medicare PIN