1124021142 NPI number — DR. MARK H DEWOLFE M.D.

Table of content: (NPI 1841215720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124021142 NPI number — DR. MARK H DEWOLFE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEWOLFE
Provider First Name:
MARK
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1124021142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 E 104TH ST
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:
64131-4517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-502-8752
Provider Business Mailing Address Fax Number:
816-932-9670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5400 N OAK TRFY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64118-4688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-454-1658
Provider Business Practice Location Address Fax Number:
816-454-1734
Provider Enumeration Date:
05/23/2005

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: 207RH0003X , with the licence number:  R3A25 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0003X , with the licence number: 04-19790 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 13192 . This is a "COVENTRY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4340992 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 12440 . This is a "HM CARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 2051670901 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201787405 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 026295099 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 09468014 . This is a "BCBS OF KANSAS CITY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1001457701 . This is a "COMMUNITY HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 497815 . This is a "BCBS OF KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 560391 . This is a "FIRSTGUARD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3650047 . This is a "UHC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 480911591028 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 97759 . This is a "ADVANTRA MEDICARE REPLACE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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