Provider Demographics
NPI:1720073638
Name:WELLPOINTE FAMILY MEDICAL
Entity Type:Organization
Organization Name:WELLPOINTE FAMILY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:417-859-7746
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0817
Mailing Address - Country:US
Mailing Address - Phone:573-335-4715
Mailing Address - Fax:573-334-2303
Practice Address - Street 1:543 W HUBBLE DR
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-1532
Practice Address - Country:US
Practice Address - Phone:417-859-7746
Practice Address - Fax:417-859-7411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014394Medicare ID - Type Unspecified