Basic Information
| Provider Information | |||||||||
| NPI: | 1629042882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | CODY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7687 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652057687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738822259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 N HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652512511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736425911 | ||||||||
| FaxNumber: | 5736423015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 08/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | R4G70 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | R4G70 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 209804624 | 05 | MO | MEDICAID |