Provider Demographics
NPI:1154341592
Name:JONATHON FALLIS DPM LLC
Entity type:Organization
Organization Name:JONATHON FALLIS DPM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:660-263-6677
Mailing Address - Street 1:1513 UNION AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270
Mailing Address - Country:US
Mailing Address - Phone:660-263-6677
Mailing Address - Fax:660-263-6688
Practice Address - Street 1:1513 UNION AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270
Practice Address - Country:US
Practice Address - Phone:660-263-6688
Practice Address - Fax:660-263-6688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004851213E00000X
MO2002006341213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP0038451OtherRAILROAD MEDICARE
MO154392OtherBCBS
MO5502300001OtherMEDICARE DMERC
IL=========6527001Medicaid
MOP0038451OtherRAILROAD MEDICARE
U67452Medicare UPIN
IL=========6527001Medicaid