Provider Demographics
NPI:1295985968
Name:OZARK GASTROENTEROLOGY, INC
Entity type:Organization
Organization Name:OZARK GASTROENTEROLOGY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ANCHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-623-5250
Mailing Address - Street 1:2216 E 32ND STREET
Mailing Address - Street 2:STE 103
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804
Mailing Address - Country:US
Mailing Address - Phone:417-623-5250
Mailing Address - Fax:417-623-8302
Practice Address - Street 1:2216 E 32ND STREET
Practice Address - Street 2:STE 103
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-623-5250
Practice Address - Fax:417-623-8302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005009627207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000093116OtherMEDICARE P10
MO1346395852OtherINDIVIDUAL NPI