Provider Demographics
NPI:1639200942
Name:VARGHESE, EBBY GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:EBBY
Middle Name:GEORGE
Last Name:VARGHESE
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:3211 S PROVIDENCE RD
Practice Address - Street 2:BLDG. C
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3644
Practice Address - Country:US
Practice Address - Phone:573-884-7100
Practice Address - Fax:573-884-7706
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050218162081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204463202Medicaid
MO204463202Medicaid
MO969012846Medicare PIN
MOP00609903Medicare PIN