Provider Demographics
NPI:1841289402
Name:SOUTHEAST MISSOURI UROLOGY CONSULTANTS PC
Entity type:Organization
Organization Name:SOUTHEAST MISSOURI UROLOGY CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINZA
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:KILLION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-471-8656
Mailing Address - Street 1:1106 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5046
Mailing Address - Country:US
Mailing Address - Phone:573-471-8656
Mailing Address - Fax:573-471-8491
Practice Address - Street 1:1106 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5046
Practice Address - Country:US
Practice Address - Phone:573-471-8656
Practice Address - Fax:573-471-8491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH8712OtherRR MEDICARE