Unknown Individual – Family Medicine Physician, NPI 1497773618

Family Medicine Physician

Unknown Individual is a healthcare provider. based in Rolla, Missouri. specializing in Family Medicine Physician. They hold a License No. 30610 (MO). The NPI Number for Unknown Individual is 1497773618

Main info

Organization

Inactive

60 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1497773618

Phone

Not provided

Address

600 BLUES LAKE PKWY

Deactivation Date

28 January 2022

Doctor Profile

Medical School Name

AT STILL UNIVERSITY OF HEALTH SCIENCES, COLLEGE OF OSTEO MED, KIRKSVILLE

Secondary Phone

5732658840

Graduation Year

1966 (60 years ago)

PAC ID

3678473576

Group Practice PAC ID

1557454063

Professional Enrollment ID

I20040109000217

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

600, Blues Lake Parkway, Rolla, Phelps County, Missouri, 65401, United States
ROLLA, MO 654018022
Phone:
Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 65401)

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Provider's Procedures

Unknown Individual performs procedures in Family Medicine Physician. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
GENERAL PRACTICE	MO	90670	Pneumococcal vaccine for injection into muscle	25	25

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 1557454063View full group profile

Name	Specialty	State
MRS. JENNIFER LYNN BREMER (P.A.)	Physician Assistant	MO
DR. JAMES J JR. SPADARO (M.D.)	-	MO
CHRISTIN HYLTON (PA-C)	-	MO
DR. ROBERT GORDON SWANSON (M.D.)	Radiation Oncology	MO
DR. BRIAN ROBERT KRIETE (M.D.)	Otolaryngology, Plastic And Reconstructive Surgery, Allergy/Immunology	MO
HALA SAMMAN (MD)	-	MO
DR. NURELIGN G. ABEBE (M.D.)	Nephrology, Internal Medicine, Hospitalist	MO
JUDYANN KRENNING (M.D.)	-	MO
MR. CRAIG TATOM (APN)	Nurse Practitioner	MO
MRS. HEATHER KOCINSKI REQUET (WHNP, CNM)	Certified Nurse Midwife (Cnm)	MO

Reviews

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Frequently asked questions

What number should I use to identify Unknown Individual for billing?

Administrative and clinical systems typically use NPI 1497773618 for Unknown Individual.

What happens when Unknown Individual's NPI is not active?

Public data lists Unknown Individual outside the active bucket for this identifier.

What does the directory say Unknown Individual does?

Insurance directories may phrase it differently, but here Unknown Individual maps to Family Medicine Physician. Clinical services aligned with this taxonomy classification.

What geographic area is tied to Unknown Individual?

Unknown Individual is associated with Rolla, Missouri in the same public data insurers reference.

Why is information missing for Unknown Individual?

Providers choose how much contact data to publish. Missing fields do not mean the profile is fake.