Provider Demographics
NPI:1356599641
Name:NEOSHO BONE & JOINT CLINIC P.C.
Entity type:Organization
Organization Name:NEOSHO BONE & JOINT CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPEDIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:REX
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-451-1833
Mailing Address - Street 1:4040 LAQUESTA DR.
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850
Mailing Address - Country:US
Mailing Address - Phone:417-451-1833
Mailing Address - Fax:417-451-1825
Practice Address - Street 1:4040 LAQUESTA DRIVE
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850
Practice Address - Country:US
Practice Address - Phone:417-451-1833
Practice Address - Fax:417-451-1825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9N57174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO246862114Medicaid
MO000094206Medicare UPIN