Provider Demographics
NPI:1609912443
Name:NORTHERN, ALLEN E (DO)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:E
Last Name:NORTHERN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1601 N BISHOP AVE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2249
Practice Address - Country:US
Practice Address - Phone:573-364-8100
Practice Address - Fax:573-341-9475
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240146126Medicaid
MO918323230Medicare PIN
MOD41688Medicare UPIN