Provider Demographics
NPI:1497908842
Name:MISSOURI SOUTHERN STATE UNIVERSITY HEALTH CENTER
Entity Type:Organization
Organization Name:MISSOURI SOUTHERN STATE UNIVERSITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTH CARE SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:W
Authorized Official - Middle Name:JANICE
Authorized Official - Last Name:DIPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:417-625-9323
Mailing Address - Street 1:3950 NEWMAN RD
Mailing Address - Street 2:KUHN HALL 306 HEALTH SERVICES OFFICE
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-1512
Mailing Address - Country:US
Mailing Address - Phone:417-625-9323
Mailing Address - Fax:417-659-4376
Practice Address - Street 1:3950 NEWMAN RD
Practice Address - Street 2:KUHN HALL 306 HEALTH SERVICES OFFICE
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1512
Practice Address - Country:US
Practice Address - Phone:417-625-9323
Practice Address - Fax:417-659-4376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1072289261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health