Provider Demographics
NPI:1619059417
Name:AVALON OBSTETRICS AND GYNECOLOGY, P.C.
Entity Type:Organization
Organization Name:AVALON OBSTETRICS AND GYNECOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SNIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-701-9600
Mailing Address - Street 1:1105 W LIBERTY ST
Mailing Address - Street 2:SUITE 2050
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1921
Mailing Address - Country:US
Mailing Address - Phone:573-701-9600
Mailing Address - Fax:573-701-9605
Practice Address - Street 1:1105 W LIBERTY ST
Practice Address - Street 2:SUITE 2050
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1921
Practice Address - Country:US
Practice Address - Phone:573-701-9600
Practice Address - Fax:573-701-9605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9B54207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODD7351OtherRAILROAD MEDICARE
MO241676840Medicaid
MOS31202Medicare UPIN
MOG24778Medicare UPIN
MODD7351OtherRAILROAD MEDICARE