Provider Demographics
NPI:1477650265
Name:PAYNE, MICHAEL KENT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENT
Last Name:PAYNE
Suffix:
Gender:M
Credentials:MD
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 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:75 SMITHSON DR
Practice Address - Street 2:SUITE A
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-9429
Practice Address - Country:US
Practice Address - Phone:417-847-3500
Practice Address - Fax:417-847-3523
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203745906Medicaid
6644OtherBLUE CROSS OF MO
916544158Medicare UPIN
P00137145Medicare PIN
6644OtherBLUE CROSS OF MO
110167726Medicare PIN
002011864Medicare PIN