Provider Demographics
NPI:1528441276
Name:CORIZON HEALTH
Entity type:Organization
Organization Name:CORIZON HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MISSOURI REGIONAL PHYSICIAN RECRUIT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-635-5315
Mailing Address - Street 1:36 STONEYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:OLIVETTE
Mailing Address - State:MO
Mailing Address - Zip Code:63132-4122
Mailing Address - Country:US
Mailing Address - Phone:314-610-1839
Mailing Address - Fax:
Practice Address - Street 1:3702 W TRUMAN BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-4970
Practice Address - Country:US
Practice Address - Phone:573-635-5315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015015777261QP2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health