Provider Demographics
NPI:1396284303
Name:SOUTHWEST MISSOURI INFECTIOUS DISEASE LLC
Entity type:Organization
Organization Name:SOUTHWEST MISSOURI INFECTIOUS DISEASE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:FULNECKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-459-1711
Mailing Address - Street 1:2872 S FORREST HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-3417
Mailing Address - Country:US
Mailing Address - Phone:417-459-1711
Mailing Address - Fax:
Practice Address - Street 1:2872 S FORREST HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-3417
Practice Address - Country:US
Practice Address - Phone:417-459-1711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004006990207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
919223268Medicare PIN