1134291107 NPI number — JAMES D BULLARD PT

Table of content: JAMES D BULLARD PT (NPI 1134291107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134291107 NPI number — JAMES D BULLARD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BULLARD
Provider First Name:
JAMES
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1134291107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2125 SE 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEES SUMMIT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64063-5127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-524-6488
Provider Business Mailing Address Fax Number:
816-524-6488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2950 NE JELLISON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUE SPRINGS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64014-0900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-507-3260
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2006

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: 2251P0200X , with the licence number:  101805 , 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: 486710726 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22381016 . This is a "BLUE CROSS BLUE SHIELD IN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".