Provider Demographics
NPI:1689662744
Name:ELDENBURG, STEVEN C (DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:C
Last Name:ELDENBURG
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 1:115 W BROADWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5708
Mailing Address - Country:US
Mailing Address - Phone:660-951-1091
Mailing Address - Fax:660-951-1046
Practice Address - Street 1:115 W BROADWAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5708
Practice Address - Country:US
Practice Address - Phone:660-951-1091
Practice Address - Fax:660-951-1046
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5P86207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431592605OtherMERCY PIN
MO080063381OtherRR MEDICARE
MO5804038OtherAETNA PIN
MO17996015OtherBLUE CROSS BLUE SHIELD/KC
MO1880OtherHEALTHCARE USA
MO243181609Medicaid
MOB747161Medicare ID - Type Unspecified
MO080063381OtherRR MEDICARE