Provider Demographics
NPI:1255432399
Name:SOUTHWEST MISSOURI BONE & JOINT, INC.
Entity type:Organization
Organization Name:SOUTHWEST MISSOURI BONE & JOINT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ELLEFSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-358-0250
Mailing Address - Street 1:1911 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-3178
Mailing Address - Country:US
Mailing Address - Phone:417-358-0250
Mailing Address - Fax:415-358-3207
Practice Address - Street 1:1911 BUENA VISTA AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-3178
Practice Address - Country:US
Practice Address - Phone:417-358-0250
Practice Address - Fax:415-358-3207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO R5N34207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODE0991OtherRR MEDICARE
MODE0991OtherRR MEDICARE