Provider Demographics
NPI:1528294634
Name:CAVERO MEDICAL GROUP LLC
Entity type:Organization
Organization Name:CAVERO MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-631-2303
Mailing Address - Street 1:1514 W LARK ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2262
Mailing Address - Country:US
Mailing Address - Phone:417-631-2303
Mailing Address - Fax:417-890-4677
Practice Address - Street 1:1514 W LARK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2262
Practice Address - Country:US
Practice Address - Phone:417-631-2303
Practice Address - Fax:417-890-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101935207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203445101Medicaid
MO101935OtherMEDICAL LICENSE
MO203445101Medicaid