Provider Demographics
NPI:1508157140
Name:SPRINGFIELD INTERNAL MEDICINE GROUP
Entity Type:Organization
Organization Name:SPRINGFIELD INTERNAL MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:417-881-4994
Mailing Address - Street 1:1435 E BRADFORD PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6563
Mailing Address - Country:US
Mailing Address - Phone:417-881-4994
Mailing Address - Fax:417-881-4998
Practice Address - Street 1:1435 E BRADFORD PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6563
Practice Address - Country:US
Practice Address - Phone:417-881-4994
Practice Address - Fax:417-881-4998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-01
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116600207R00000X
MO2010006173363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty