Provider Demographics
NPI:1942475785
Name:WELLPOINTE FAMILY MEDICAL
Entity Type:Organization
Organization Name:WELLPOINTE FAMILY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-651-4488
Mailing Address - Street 1:543 W HUBBLE DR
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706-1532
Mailing Address - Country:US
Mailing Address - Phone:417-859-4878
Mailing Address - Fax:417-859-4878
Practice Address - Street 1:543 W HUBBLE DR
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-1532
Practice Address - Country:US
Practice Address - Phone:417-859-4878
Practice Address - Fax:417-859-4878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509460507Medicaid