Provider Demographics
NPI:1457371072
Name:TINES, STEPHEN C (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:TINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 NW 1ST LN
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-8105
Mailing Address - Country:US
Mailing Address - Phone:417-681-5100
Mailing Address - Fax:417-681-5521
Practice Address - Street 1:29 NW 1ST LN
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-8105
Practice Address - Country:US
Practice Address - Phone:417-681-5100
Practice Address - Fax:417-681-5521
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK163042085R0202X
MOR5B342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500100001Medicare PIN