Provider Demographics
NPI:1790726560
Name:BRUCE ROTTON SURGICAL, LLC
Entity Type:Organization
Organization Name:BRUCE ROTTON SURGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROTTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:417-337-7260
Mailing Address - Street 1:650 BRANSON LANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-2089
Mailing Address - Country:US
Mailing Address - Phone:417-337-7260
Mailing Address - Fax:417-337-7263
Practice Address - Street 1:650 BRANSON LANDING BLVD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2089
Practice Address - Country:US
Practice Address - Phone:417-337-7260
Practice Address - Fax:417-337-7263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504968801Medicaid
MO504968801Medicaid