Basic Information
| Provider Information | |||||||||
| NPI: | 1780614495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOUBA | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | MILLER | ||||||||
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| Credential: | MD | ||||||||
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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: | ONE HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652120001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738849066 | ||||||||
| FaxNumber: | 5738843037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2001009493 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 2080A0000X | 2001009493 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 147494 | 01 | MO | BLUESHIELD/BLUE CHOICE | OTHER | 464041 | 01 | MO | HEALTHLINK | OTHER | 205363906 | 05 | MO | MEDICAID | 405522 | 01 | MO | UNITED HEALTHCARE | OTHER |