Provider Demographics
NPI:1568457463
Name:BIRD, JONATHON M (MD)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:M
Last Name:BIRD
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 1:255 BODERMAN
Mailing Address - Street 2:
Mailing Address - City:BLOOMSDALE
Mailing Address - State:MO
Mailing Address - Zip Code:63627-9099
Mailing Address - Country:US
Mailing Address - Phone:573-483-9492
Mailing Address - Fax:573-483-9612
Practice Address - Street 1:255 BODERMAN
Practice Address - Street 2:
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627-9099
Practice Address - Country:US
Practice Address - Phone:573-483-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9D20207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202450854Medicaid
196690OtherBLUE CROSS BLUE SHIELD
MO202450847Medicaid
MO202450854Medicaid
MO001013210Medicare PIN
MOC52321Medicare UPIN
MO001013211Medicare PIN
196690OtherBLUE CROSS BLUE SHIELD