Provider Demographics
NPI:1508813833
Name:NOLL, BETTY ANNE (MD)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:ANNE
Last Name:NOLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W WORLEY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2037
Mailing Address - Country:US
Mailing Address - Phone:573-214-2314
Mailing Address - Fax:
Practice Address - Street 1:1600 N MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:MARCELINE
Practice Address - State:MO
Practice Address - Zip Code:64658-1012
Practice Address - Country:US
Practice Address - Phone:660-376-2038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8J07207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00322457OtherRAILROAD MEDICARE
MO1508813833Medicaid
MO1508813833Medicare PIN
MOP00322457OtherRAILROAD MEDICARE