Provider Demographics
NPI:1740294396
Name:MONROE, MARK H (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:MONROE
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 1:311 N KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6623
Mailing Address - Country:US
Mailing Address - Phone:573-442-1788
Mailing Address - Fax:573-442-1789
Practice Address - Street 1:311 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6623
Practice Address - Country:US
Practice Address - Phone:573-442-1788
Practice Address - Fax:573-442-1789
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040216012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208383604Medicaid
MO922970365Medicare PIN
MO922975276Medicare PIN
F51288Medicare UPIN
MO208383604Medicaid
MOP00144503Medicare PIN
MO922973832Medicare PIN