Provider Demographics
NPI:1659413730
Name:COLLISON, R. MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:R.
Middle Name:MICHAEL
Last Name:COLLISON
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: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 1:2730 E SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2047
Practice Address - Country:US
Practice Address - Phone:417-883-0600
Practice Address - Fax:417-883-9443
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7D68207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202014536Medicaid
MO83025OtherAR BLUE SHIELD #
MO146013268Medicare PIN
MO83025OtherAR BLUE SHIELD #
MO202014536Medicaid