# RETIRED

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1962818435
- **Authorized official:** HERB BASTOW M.D. (UROLOGIST)
- **Authorized official phone:** (573) 696-2391

## Contact information

- **Practice address:** 13714 N SPORTSMANS DR, HALLSVILLE, MO 65255-9330
- **Practice address phone:** (573) 696-2391
- **Mailing address:** 13714 N SPORTSMANS DR, HALLSVILLE, MO 65255-9330
- **Mailing address phone:** (573) 696-2391

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | R5108 | MO | Yes |

## Other

- **Enumeration date:** 07/06/2014
- **Last updated:** 07/06/2014