Provider Demographics
NPI:1316905441
Name:PEDIATRIX MEDICAL GROUP OF SPRINGFIELD
Entity type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP OF SPRINGFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NOENATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VISWANATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUBRAMANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-820-3219
Mailing Address - Street 1:1369 N BRISTOL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2231
Mailing Address - Country:US
Mailing Address - Phone:417-820-3219
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-3219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD1122662080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH37499Medicare UPIN