1114084522 NPI number — DR. TIMOTHY O WALTNER MD

Table of content: DR. TIMOTHY O WALTNER MD (NPI 1114084522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114084522 NPI number — DR. TIMOTHY O WALTNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTNER
Provider First Name:
TIMOTHY
Provider Middle Name:
O
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114084522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 419380 - DEPT 128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64141-6380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-642-4900
Provider Business Mailing Address Fax Number:
913-381-0979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 CLAY EDWARDS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64116-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-691-5201
Provider Business Practice Location Address Fax Number:
816-346-7063
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085N0700X , with the licence number:  2005010786 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 2005010786 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9499055 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1114084522 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200270670B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38347013 . This is a "BCBSKC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00397045 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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