Provider Demographics
NPI:1942605175
Name:MISSOURI CANCER ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MISSOURI CANCER ASSOCIATES, LLC
Other - Org Name:UROLOGY ASSOCIATES OF CENTRAL MISSOURI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:TUNGESVIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-874-7800
Mailing Address - Street 1:1705 E BROADWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7166
Mailing Address - Country:US
Mailing Address - Phone:573-874-7800
Mailing Address - Fax:573-874-8620
Practice Address - Street 1:105 N KEENE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8131
Practice Address - Country:US
Practice Address - Phone:573-499-4990
Practice Address - Fax:573-442-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1144430002Medicare NSC