Provider Demographics
NPI:1780852384
Name:ROLLA CHILDREN'S CLINIC, P.C.
Entity Type:Organization
Organization Name:ROLLA CHILDREN'S CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-364-1900
Mailing Address - Street 1:1050 W 10TH ST
Mailing Address - Street 2:SUITE 480
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-1900
Mailing Address - Fax:573-364-7365
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:SUITE 480
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-364-1900
Practice Address - Fax:573-364-7365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty