Basic Information
| Provider Information | |||||||||
| NPI: | 1558919852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYNERGOS MEDICAL, LLC | ||||||||
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| OtherOrganizationName: | SYNERGOS MEDICAL, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 N KEENE ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736151703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1703 OAK CLIFF PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652034719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2019 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | BETTIS | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5737775880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.