Provider Demographics
NPI:1568642452
Name:OTOLARYNGOLOGY OF JOPLIN INC.
Entity Type:Organization
Organization Name:OTOLARYNGOLOGY OF JOPLIN INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-781-4613
Mailing Address - Street 1:1920 E 32ND ST.
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804
Mailing Address - Country:US
Mailing Address - Phone:417-781-4613
Mailing Address - Fax:417-781-0805
Practice Address - Street 1:1920 E 32ND ST.
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-781-4613
Practice Address - Fax:417-781-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104366261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO248651705Medicaid
MOG44799Medicare UPIN