Provider Demographics
NPI:1639135437
Name:COVERT, BRANDON W (DO)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:W
Last Name:COVERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-6611
Mailing Address - Fax:417-347-6662
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-6611
Practice Address - Fax:417-347-6662
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190242272085R0202X
TXM25912085R0202X
MO20040300072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
843471OtherBCBS KS FOR MO LOCATION
KS200346940DMedicaid
P00364462OtherRR MEDICARE GROUP CK7871
106093OtherBCBS KS FOR KS LOCATION
MO207364902Medicaid
MO35466021OtherBCBS OF KC
MO207364902Medicaid
TX8L13329Medicare PIN
106093OtherBCBS KS FOR KS LOCATION
KS200346940DMedicaid