Provider Demographics
NPI:1831269695
Name:MID-MISSOURI NEONATOLOGY LLC
Entity type:Organization
Organization Name:MID-MISSOURI NEONATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE AND BILLING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-815-9700
Mailing Address - Street 1:PO BOX 10200
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-4003
Mailing Address - Country:US
Mailing Address - Phone:573-815-9700
Mailing Address - Fax:573-815-0700
Practice Address - Street 1:1600 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5844
Practice Address - Country:US
Practice Address - Phone:573-815-3737
Practice Address - Fax:573-815-3716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO129002OtherANTHEM BCBS GROUP PIN
26831OtherGHP GROUP PIN
19413OtherHEALTH CARE USA GROUP PIN
26831OtherGHP GROUP PIN